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Full text of "A manual of diseases of the throat and nose : including the pharynx, larynx, trachea, oesophagus, nose and naso-pharynx"

YALE 
MEDICAL LIBBARY 




HISTORICAL 
LIBRARY 



THE GIFT OF 

FREDERICK N. SPERRY 



A MANUAL OF DISEASES 



OF THE 



THROAT AND NOSE 



INCLUDING THE 



PHARYNX, LARYNX, TRACHEA, (ESOPHAGUS, 
NOSE. AND NASO-PHARYNX 



BY 

MORELL MACKENZIE, M.D., Lond., 

\\\ 

CONSULTING PHYSICIAN TO THE H06PITAL FOR DISEASES OF THE THROAT ; LECTURER ON DISEA6ES OF 

THE THROAT AT THE LONDON HOSPITAL MEDICAL COLLEGE, AND CORRESPONDING MEMBER 

OF THE IMPERIAL ROYAL SOCIETY OF PHYSICIANS OF VIENNA 



TWO VOLUMES IN ONE 



VOL. I.— DISEASES OF THE PHARYNX., 
LARYNX, AND TRACHEA 



PUBLISHERS 

WILLIAM WOOD & COMPANY 
NEW YORK 



TROW DIRECTORY 

PRINTING AND BOOKBINDING COMPANY 

NEW YORK 



RP48 
8©otv\ 



PREFACE. 



This work is based partly on the courses of lectures which I have 
annually delivered at the London Hospital Medical College during 
the last twelve years, and partly on my essay on " Diseases of the 
Larynx," to which the Jacksonian Prize was awarded by the Royal 
College of Surgeons of England. Some of my lectures have appeared 
in the British Medical Journal, Lancet, and Medical Times and Ga- 
zette, but by far the larger portion of the matter contained in these 
pages is now published for the first time. 

The classification of disease is always attended with considerable 
difficulty, and at present no single system can be rigidly adhered to. 
For even accepting pathology as the basis, the tissues themselves are 
of so composite a character, and there are so many " organs within 
organs " in the human frame, that logical precision cannot be main- 
tained, except by pedantic subdivisions, which would defeat the ob- 
ject of the arrangement. Again, whilst some throat affections are 
strictly circumscribed in their ravages, others attack different sections 
of the air-passages at the same time. Hence, although this work has 
been divided into certain primary sections, and as a rule each disease 
has been separately considered in its proper division ; yet in some 
cases it has been found more convenient to depart from this plan, and 
to treat the morbid phenomena of contiguous parts together. 

The system of nomenclature issued by the Royal College of Physi- 
cians has been adopted with such modifications and additions as the 
consideration of a special class of diseases rendered necessary. 

Records of cases have, as a rule, only been introduced where they 



IV PKEFACJ 

were required for the illustration of a difficult subject, or where the 
cases themselves were exceptionally rare. 

The views which I entertain as regards the use of mercury in 
syphilis will probably meet with some opposition, but having followed 
Professor Siginund's practice in Vienna in 1859 and 1860, I became 
well acquainted with his views at an early period of my medical ca- 
reer, and a somewhat extensive experience in dealing with the con- 
stitutional phenomena of syphilis has since convinced me of the truth 
of the fundamental views entertained by the eminent Viennese Pro- 
fessor, viz. : — (1) That specific anti-syphilitic treatment is only re- 
quired when serious constitutional symptoms are present ; (2) that 
specific treatment in the early stages does not ward off the later man- 
ifestations of the affection ; (3) that local treatment, analeptic reme- 
dies, and hygienic measures are of the utmost importance ; (4) that 
the disease itself, except under unfavorable circumstances, tends to- 
ward spontaneous cure ; and (5) that the development of serious 
pathological changes depends on conditions inherent in the patient 
himself. These views have been sustained by Professor Sigmund 
with all his old energy in the recent edition of his well known " Vor- 
lesungen fiber neuere Behandlungsweisen der Syphilis." It will, 1 
hope, be understood that whilst employing iodide of potassium more 
frequently, I nevertheless consider mercury a valuable, and in some 
cases an indispensable, remedy in syphilis. 

Whilst placing the results of my own experience before the pro- 
fession, I have endeavored to do full justice to the many physicians, 
both ancient and modern, who have elucidated the class of affections 
herein discussed ; and if, in any case, I have failed to acknowledge 
the labors of others, I trust that the error will be looked upon as acci- 
dental. 

I am indebted to many distinguished authors for kindly forward- 
ing me their valuable works and new editions, and I much regret that 
I was only able to make use of some of them for a few casual refer- 
ences, in consequence of their not having reached me until the greater 
part of this volume was already in type. This remark especially ap- 
plies to the second edition of Dr. Solis Cohen's excellent work on 
" Diseases of the Throat and Nasal Passages,'' and to the second (Ger- 



PREFACE. V 

man) edition of Prof. Ziemssen's able contribution on the " Krank- 
heiten des Kehlkopfes " to his own Encyclopaedia ; it applies also to 
Dr. Max Schuller's exhaustive article in the " Deutsche Chirurgie," 
entitled " Tracheotomie, Laryngotomie, und Exstirpation des Kehl- 
kopfes," and to Prof. Stoerk's comprehensive treatise in the same 
series on the " Krankheiten des Kehlkopfes, der Nase, und des Ra- 
chens." For the reason' stated above I have also been obliged to forego 
the satisfaction of even referring to many other smaller works, to 
which I hope to do justice on a future occasion. 

Incomplete as the work is in many respects, yet, owing to my nu- 
merous professional engagements, I could not have collected the 
materials on which it is founded had it not been for the assistance I 
have received from many friends. It would be difficult to assign to 
each the due amount of my obligations, and I must therefore content 
myself by thanking them collectively. There are a few, however, 
whose names cannot be altogether omitted. Thus, I am especially in- 
debted to my colleague, Dr. Semon, who has prepared a German 
translation of this work (to appear simultaneously with the English 
edition), for many important suggestions and much keen criticism; I 
have to thank my former assistant, Dr. Gordon Holmes, for valuable 
aid in matters of historical research, more particularly in connection 
with those authors whose observations are recorded in the classical 
languages ; and I am very grateful to Mr. Mark Hovel, Resident Med- 
ical Officer and Registrar to the Hospital for Diseases of the Throat 
.and Chest, for preparing a detailed index. 

M. M. 

19 Harley Street, London, 
May, 1880. 



CONTENTS. 



SECTION I.— THE PHARYNX. 

PAGB 

Anatomy of the Pharynx ; The Examination of the Pharynx ; Pharyngeal In- 
struments ; Diseases of the Pharynx : Catarrh of the Pharynx ; Uvulitis ; 
Retro- pharyngeal Abscess ; Relaxed Throat and Uvula ; Ulcerated Throat ; 
Granular Pharyngitis ; Putrid Sore Throat ; Herpes of the Pharynx ; Rheu- 
matic Sore Throat ; Gouty Sore Throat ; Tonsillitis ; Enlarged Tonsils ; 
Foreign Bodies in the Tonsils ; Parasites in the Tonsils ; Dilatation of the 
Pharynx ; Cancer of the Pharynx ; Cancer of the Tonsils ; Non-malignant 
Tumors of the Pharynx ; Syphilis of the Pharynx ; Phthisis of the Phar- 
ynx ; Traumatic Pharyngitis ; Anginas caused by Poisonous Drugs ; Wounds 
of the Pharynx ; Foreign Bodies in the Pharynx ; Neuroses of the Phar- 
ynx : Neuroses of Sensation ; Neuroses of Motion ; Aphthae ; Diphtheria ; 
Laryngotracheal Diphtheria, formerly called Croup ; Nasal Diphtheria ; 
The Throat Affections of the Eruptive Fevers : Scarlet Fever ; Measles ; 
Small-pox ; The Throat Affections of Typhoid Fever ; Typhus ; Intermit- 
tent Fever ; Erysipelas of the Pharynx and Larynx 1-147 



SECTION II.— THE LARYNX. 

Anatomy of the Larynx ; The Laryngoscope and its Accessory Apparatus ; Lar- 
yngoscopy ; Auto-Laryngoscopy ; Infra-glottic Laryngoscopy ; The Laryn- 
geal [mage ; Laryngeal Instruments ; Dilators of the Larynx ; Acute Catar- 
rhal Laryngitis ; CEdematous Laryngitis ; Traumatic Laryngitis ; Abscess 
of the Larynx ; Chronic Laryngitis ; Chronic Glandular Laryngitis; Phle 
bectasis Laryngea ; Trachoma of the Vocal Cords ; Sub-glottic Chronic 
Laryngitis ; Chronic (Edema of the Larynx ; Non-malignant Tumors of the 
Larynx ; Malignant Tumors of the Larynx ; Cancer of the Larynx ; Sec- 
ondary Cancer ; Sarcomata ; Syphilis of the Larynx ; Laryngeal Phthisis ; 
Perichondritis of the Larynx and Necrosis of the Cartilages ; Lupus of the 
Larynx ; Cases illustrating Lupus of the Larynx ; Leprosy of the Larynx ; 
Cases illustrating Leprosy of the Larynx ; Fractures and Dislocations of 
the Larynx ; Fracture and Dislocation of the Hyoid Bone ; Wounds of 
the Larynx; Burns of the Larynx; Foreign Bodies in the Larynx ; Case of* 
Impaction of a Lamella of Bone Transversely in the Ventricles ; Nervo- 



VI U CONTENTS. 

PA»E 

Muscular and Sensory Affections of the Larynx ; Anaesthesia of the Lar- 
ynx ; Cases of Anaesthesia of the Larynx after Diphtheria ; Hyperassthesia, 
Parassthesia, and Neuralgia; Laryngeal Paralysis from Disease or Injury 
of the Medulla Oblongata ; Cases illustrative of Paralyses from Disease of 
the Medulla Oblongata ; Laryngeal Paralysis from Disease or Injury of the 
Spinal Accessory Nerve ; Laryngeal Paralysis from Disease or Injury of the 
Pneumogastric Nerve ; Laryngeal Paralysis from Disease or Injury of the 
Superior Laryngeal Nerve ; Case of Inflamed Cervical Glands pressing on 
the Superior Laryngeal Nerves ; Laryngeal Paralysis from Disease or In- 
jury of the Recurrent Nerve ; Bilateral Paralysis ; Cases illustrating Com- 
plete and Partial Bilateral Paralysis of the Recurrent Nerves ; Unilateral 
Paralysis : Paralysis of Individual Laryngeal Muscles ; Paralysis of the Ab- 
ductors of the Vocal Cords ; Cases illustrative of Bilateral Paralysis of the 
Abductors ; Paralysis of one Abductor ; Cases illlustrating Paralysis of one 
Abductor; Bilateral Paralysis of the Adductors of the Vocal Cords ; Paral- 
ysis of One Lateral Adductor ; Cases illustrating Paralysis of One Lateral 
Adductor ; Paralysis of the Central Adductor (Inter- Arytenoid Muscle) ; 
Paralysis of the External Tensors of the Vocal Cords (Crico-Thyroid Mus- 
cles) ; Cases illustrating Paralysis of the External Tensors ; Paralysis of the 
Internal Tensors of the Vocal Cords (Thryo-Arytenoidei Interni) ; Mixed 
Paralyses ; Atrophy of the Vocal Cords ; Anchylosis of the Arytenoid Artic- 
ulation ; Spasm of the Glottis ; Spasm of the Glottis in Adults ; Nervous 
Laryngeal Cough ; Spasm of the Tensors of the Vocal Cords ; Chorea of 
the Larynx ; Malformations of the Larynx 148-363 



SECTION III.— THE TRACHEA. 

Anatomy of the Trachea ; Surgical Anatomy of the Laryngo-Tracheal Region ; 
Tracheoscopy ; The Tracheal Image ; Tracheal Instruments ; Tracheotomy 
Instruments ; Accessory Instruments used in connection with Tracheal Ca- 
nulae ; Acute Catarrhal Tracheitis ; Chronic Tracheitis ; Non-Malignant Tu- 
mors in the Trachea ; Short Abstracts of all the Cases of Tracheal Growths 
observed by the Author; Osseous Growths; Post-Tracheotomic Vegeta- 
tions ; Malignant Tumors of the Trachea ; Cancer of the Trachea ; Case of 
Cancer of the Trachea; Cancer from Contiguity ; Sarcoma of the Trachea; 
Syphilis of the Trachea ; Stricture of the Trachea ; Compression of the 
Trachea ; Tracheal Phthisis ; Wounds of the Trachea ; Bronchotomy, in- 
cluding Tracheotomy and (Crico-Thyroid) Laryngotomy ; Tracheotomy ; 
Laryngotomy (Crico-Thyroid) : Laryngo-Tracheotomy ; Thermo- Cautery in 
Laryngo-Tracheal Operations ; Withdrawal of the Canula ; Tracheocele ; 
Foreign Bodies in the Trachea ; Malformations of the Trachea 364-418 



APPENDIX. 

Special Formulas for Topical Remedies : Steam Inhalations ; Spray Inhalations ; 
Fuming Inhalations ; Gargles ; Lozenges ; Pigments ; Insufflations ; Nu- 
tritive Enema ; Metric Measurements compared with the English Inch. . .419-426 



DISEASES 



OF THE 



PHARYNX, LARYNX, AND TRACHEA 



SECTION I.-THE PHARYNX. 



ANATOMY OF THE PHARYNX. 

The pharynx is that portion of the alimentary tube which corresponds in 
extent to the interval between the basilar process of the occipital bone 
above and the interval between the fourth and fifth cervical vertebrae be- 
low. It is continuous below with the oesophagus and larynx, in front 
with the nasal and oral cavities, and above with the ear. It may be de- 
scribed as an irregularly flattened cylinder, wider above than below, and 
slightly concave anteriorly, applied to the anterior surface of the verte- 
brae. Its roof, which lies immediately below the skull, is quadrilateral, 
with rounded edges. It is concave in an antero-posterior direction, di- 
rectly continuous with its posterior wall, and in form, may not inaptly be 
compared to the hood of a carriage. The pharynx is freely movable over 
the cervical spine, and thus permits the various movements which take 
place in swallowing and respiration. It is in relation with the following 
structures: posteriorly, with the pre-vertebral muscles, which are covered 
by a strong aponeurosis, and from which it is separated by the retro- 
pharyngeal cellular tissue; laterally, with the carotids, the internal jugu- 
lar veins, the eighth pair of nerves, the sympathetic nerve, and a chain of 
lymphatics and ganglia; anteriorly, with the nasal fossae, soft palate, isth- 
mus of the fauces, dorsum of tongue, and posterior aspect of the larynx. 
The maximum length of the pharynx in the adult is about five inches, 
and its superior transverse diameter about one inch and three-fifths. It 
is slightly wider opposite the cornua of the hyoid bone, and opposite the 
cricoid cartilage it ag-am becomes contracted. Its diameter, in an antero- 
posterior direction, is about four-fifths of an inch superiorly. Below, its 
anterior and posterior surfaces are in contact in the centre. Its osseous 
relations are: superiorly, the basilar portion of the occipital, and the 
body of the sphenoid, bone, and the so-called basilar fibro-cartilage; an- 
teriorly and above, the vomer in the mesial line; laterally, the internal 
1 



2 

pterygoid plates of the sphenoid bone; below, the horizontal plates of the 
palate bone; and posteriorly, the anterior surface of the five upper cervi- 
cal vertebrae, with their fibro-cartilages. 

The pharynx consists essentially of a fibrous framework, lined by mu- 
cous membrane, and containing a complex muscular layer, with blood-ves- 
sels and nerves. These elements will be described in the order they are 
met with in actual examination, a general idea of the inner aspect of the 
cavity being first given. 

For convenience of description, the pharynx may be regarded as con- 
sisting of a pharyngo-nasal, a pharyngo-oral, and a pharyngo-laryngeal 
cavity. The former is concerned in respiration and in the modification of 
the tone of the voice; the second and third, in both respiration and deg- 
lutition. 

The pharyngo-nasal space is continuous anteriorly with the nasal cav- 
ities, and laterally communicates by means of the Eustachian tube with 
the middle ear. The upper wall or roof, already described, is rich in 
gland tissue, and shows numerous depressions and crypts. In some sub- 
jects there is a cavity of considerable depth situated posteriorly and in 
the centre of the roof, in which are found the openings of numerous fol- 
licles. This collection of follicles has been described by Luschka 1 as an 
aggregated acinous gland, and named the " pharyngeal tonsil," in contra- 
distinction to the analogous glands in the fauces. This tonsil is about a 
centimetre in thickness, and is situated near the vault of the pharynx, 
between the orifices of the two Eustachian tubes. It is covered with the 
ciliated epithelium found in this portion of the cavity. The gland is 
composed of follicles more or ress compactly united, and its surface is 
dotted by a number of small prominences — the openings of the glandule. 
The pharyngeal tonsil is not enclosed within a proper capsule, the reticu- 
lar connective tissue of the gland being continuous with that of the ad- 
jacent mucous membrane. According to Tortual 3 there is a deepish 
sinus at the anterior border of the roof, which he calls the sinus faucium 
superior; it extends forward from the semilunar fold of mucous mem- 
brane at the border of the posterior nares, externally and below the upper 
edge of the orifice of the Eustachian tube. The lateral walls of this cav-. 
ity are limited superiorly by the openings of the Eustachian tubes and the 
recessus pharyngeus, or fossa of Rosenmuller. The opening of the car- 
tilaginous portion of the Eustachian tube lies on the level of the poste- 
rior nares, and is about one-fifth of an inch below the base of the skull, 
and about three inches and one-fifth from the anterior nares. The aper- 
ture is about two-fifths of an inch in its vertical, and about one-fifth in 
its transverse, diameter. That portion of it which appears in the pharynx 
is covered by mucous membrane, and is seen as a somewhat rounded ele- 
vation, with its convexity turned upward and backward; from its upper 
extremity a fold of mucous membrane extends to the border of the pos- 
terior nares, and from its posterior extremity another fold extends to the 
hinder surface of the velum pendulum palati. Between the orifice of the 
Eustachian tube and the posterior wall of the pharynx is a somewhat tri- 
angular shaped depression, covered with numerous glands, which is known 
as Kosenmiiller's fossa. The posterior wall of this portion of the pharynx 
is almost vertical, and lies in front of the pharyngeal fascia, the anterior 
arch of the atlas, and the body of the axis. Its mucous surface is smooth, 

1 Der Schlundkopf des Menschen, Tubingen, 18G8, p. 110. 
2 Luschka: Op. cit. p. lb. 



ANATOMY OF THE PHARYNX. 6 

and shows the openings of numerous acini. The anterior wall presents 
the choanae, separated by the septum narium, and below them the poste- 
rior surface of the soft palate (vide p. 5). 

The pharyngo-oral cavity may be said to be limited superiorly by the 
level of the base of the uvula, and below by a plane passing through the 
posterior extremities of the greater cornua of the hyoid bone. The pos- 
terior surface of the uvula must be regarded as its incomplete anterior 
wall, the pillars of the fauces its lateral walls, and the base of the tongue, 
together with the folds of mucous membrane enclosing some muscular 
tissue, and known as the pharyngo-epiglottic folds, its lower margin. 

The pharvngo-laryngeal cavity occupies the position corresponding 
with the hyoid bone above and the inferior border of the cricoid cartilage 
below. On its anterior surface, running obliquely downward and slightly 
forward, is the upper portion of the glosso-epiglottic fold on each side; 
in the middle, is the epiglottis; whilst the lower border of the cricoid car- 
tilage may be regarded as its inferior limit. The posterior wall of this 
portion of the pharynx is channelled out, and not flat as in the upper re- 
gions. Its anterior wall is wanting centrally, owing to the opening of 
the larynx. Laterally, the anterior wall of this portion of the pharynx 
presents a fossa on each side, the pharvngo-laryngeal sinus, which is 
about half an inch in its antero-posterior diameter and somewhat broader 
laterally. 

The pharyngeal walls average about one-tenth of an inch in thickness, 
and are formed of mucous membrane and glands, muscles, fibrous tissue, 
blood-vessels, lymphatics, and nerves. 

The mucous membrane is applied to the entire internal surface of the 
pharynx, and is continuous with all the openings into it; it is slightly 
adherent to the underlying tissues in the upper portion, but below, in the 
laryngeal region, it becomes very lax. The structure of the mucous 
membrane is partly fibrous tissue and partly connective, varying with its 
position, in the greater part of the pharyngo-nasal cavity. Lower down 
it is denser than above, and contains an abundance of glandula?. The epi- 
thelium in the pharyngo-nasal cavity, the surface of which is of a pale 
rose color, is cylindrical and ciliated, whilst in the pharyngo-oral region 
and below it is tesselated, and somewhat redder. 

The glands are of two kinds, conglomerate and follicular. In the 
pharyngo-nasal cavity the former are most abundant, particularly at the 
posterior border of the Eustachian tubes and on the pharyngeal surface 
of the velum pendulum palati, where they are clustered together. They 
are more sparsely distributed lower down. The follicular glands are 
found in the pharyngo-oral cavity, and in the roof of the pharyngo-nasal 
cavity they are collected together and form " Luschka's tonsil," already 
described. 

The fibrous structure of the pharynx forms a complete investment, and 
serves to maintain its form. It is very tough and strong, and has the 
fibres of the several muscles attached to it. It is attached superiorly and 
centrally to the basilar process of the occipital bone through the inter- 
vention of the cranio-pharyngeal ligament, and laterally to the petrous 
portions of the temporal bones, hanging suspended as it were from these 
points. Its internal surface is covered by the pharyngeal mucous mem- 
brane, whilst its external surface supports the muscles of the pharynx. 
Below it becomes continuous with the cellular tissue of the oesophagus. 
Laterally, it is attached to the posterior border of the internal pterygoid 
plate of the sphenoid bone, to the pterygo-maxillary ligament, the poste- 



4 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

rior portion of the mylo-hyoid ridge, the stylo-hyoid ligament, the cornua 
of the hyoid bone, the thyrohyoid membrane, and the posterior border of 
the thyroid, and the external surface of the cricoid cartilage. 

The muscles of the pharynx consist of the three pairs of constrictors: 
the superior, middle, and inferior, which are arranged in layers, and the 
stylo-pharyngei. 

The superior constrictors are flat quadrilateral muscles, the fibres of 
which are parallel to each other and directed horizontally. Their fixed 
insertion is to the lower portion of the internal pterygoid plate, the apo- 
neurosis of the soft palate, the pterygo-maxillary ligament, and posterior 
portion of the mylo-hyoid ridge, and slightly to the side of the tongue. 
Their movable attachment is to the median raphe, where some of the fibres 
of the muscles interlace. The muscular fibres from the internal pterygoid 
plate pass obliquely upward to the median raphe at the base of the skull, 
forming a kind of festoon on either side of the middle line; the inter- 
space is filled in by the pharyngeal aponeurosis and the mucous mem- 
brane (sinus of Morgagni). The middle constrictors lie in a plane poste- 
rior to the superior constrictors, their fixed attachments^, being to the 
greater and lesser cornua of the hyoid bone; from these the fibres pass 
backward in the shape of a fan, the superior ones passing upward and in- 
ward and covering the superior constrictor, the middle passing trans- 
versely, and the inferior downward and inward. They are ultimately' 
partly inserted in the median raphe, and partly into the pharyngeal apo- 
neurosis — interlacing- with each other. The inferior constrictors lie in a 
plane posterior to the middle, and have as their fixed attachments, ante- 
riorly, the posterior border of the thyroid cartilage and the triangular 
surface on its outer wall, and the sides of the cricoid cartilage; from these 
points the fibres pass backward, the inferior horizontally, and the supe- 
rior upward and inward. In the middle line the fibres are inserted into 
the pharyngeal aponeurosis, interlacing with one another, and with the 
inferior fibres of the middle constrictor. The stylo-pharyngei are long, 
delicate muscles arising from the bases of the styloid processes, and pass- 
ing downward, forward, and inward; the fibres expand and become in- 
serted into the posterior border of the thyroid cartilage. At first this 
muscle is applied to the outer surfaces of the superior constrictor, but 
passing between the inner surface of the middle constrictor and the 
pharyngeal aponeurosis, it spreads out before it is inserted. These mus- 
cles are covered on their outer surfaces by the external fascia, which in 
the lower two-thirds of the pharynx is derived from the deep cervical, 
and at the upper third from the bucco-pharyngeal, fascia; whilst inter- 
nally the fascia applied to them is the cephalo-pharyngeal, which is at- 
tached to the fibro-cartilage at the base of the skull. 

The arteries are: the ascending pharyngeal from the external carotid, 
which supplies the chief portion of the region and the Eustachian tube; 
and anteriorly and laterally, behind and above the openings of the 
choan;e, some terminal twigs of the internal maxillary, the vidian, and 
spheno-palatine, which inosculate freely with each other. The veins an/ 
collected into a dense plexus in the deeper layers, and terminate in the 
internal jugular. The lymphatics form a network in the mucous mem- 
brane, and also in the muscular structures, and terminate in glands situa- 
ted at the base of the skull and near the greater cornua of the hyoid bone. 
(1 Aischka.) 

The nerves are derived from the second division of the fifth, which 
supplies the roof and orifice of the Eustachian tube, and from some twigs 



ANATOMY OF THE PHARYNX. 5 

of the third division, which, however, more particularly pass to the soft 
palate. The glossopharyngeal nerve supplies the stylo-pfoaryngeus, the 
superior and middle constrictors, and the mucous membrane. The pha- 
ryngeal branches of the vagus, and glosso-pharyngeus, and the spinal ac- 
cessory, communicate and supply the upper and middle constrictors and 
the mucous membrane (Hyrtl and Riidinger), whilst the superior laryn- 
geal supplies the superior constrictor. The sympathetic nerves are de- 
rived from the superior cervical and middle cervical ganglia. 



The Soft Palate. 

The soft palate is a movable curtain continued backward from the 
hard palate. It has two surfaces of mucous membrane, a posterior, con- 
tinuous with that of the nasal cavity, and an anterior, continuous with 
the lining membrane of the mouth. Between these mucous surfaces is 
a stratum of muscular tissue. The soft palate (or velum pendulum palati) 
has the uvula in the centre, and laterally the pillars of the fauces, enclos- 
ing the tonsil. Its direction is obliquely backward and downward, as re- 
gards the hard palate. It is variable in thickness, averaging from one- 
fifth of an inch to about half an inch; its depth varies from an inch to an 
inch and a half, and from its crescentic shape it is deeper in the centre 
than at the sides. Between the pillars of the fauces laterally, the margin 
of the velum above, and the root of the tongue below, is an opening, 
capable of many and varied movements — the isthmus of the fauces. 

The anterior surface of the soft palate, which forms a portion of the 
mouth, presents on each side a sharp-edged free margin, springing from 
the base of the uvula, and curving downward to the tongue, constituting 
the anterior pillar of the fauces. The mucous membrane on this anterior 
aspect has a smooth surface, and contains a stratum of acini closely packed 
together and continuous with those of the hard palate. In its mesial line 
is a vertical raphe — the indication of the fusion of the sides during em- 
bryonic life. Its posterior surface constitutes a portion of the anterior 
w T all of the pharynx, and is formed also by two sickle-shaped processes or 
folds, whose margins diverge from the uvula as on the anterior surface, 
but they are thicker and their edges more rounded. Their upper extrem- 
ities commence at the base of the uvula, and forming; smaller arches than 
those on the anterior surface, pass backward and downward, becoming 
flatter as they descend, and losing themselves in the lateral walls of the 
pharynx. The mucous membrane is thickly studded with glands, which 
form a continuous layer (solitary follicles). The epithelium is of the 
squamous variety, excepting near the orifices of the Eustachian tubes, 
where it is ciliated. 

The uvula hangs from the centre of the soft palate, as a conical pro- 
cess about a quarter of an inch in length, having the two crescentic folds 
of the margin of the velum on either side. It is composed of mucous 
membrane very rich in glands, and contains the azygos uvulre muscles. 

The tonsils lie between the pillars of the fauces, in a sort of niche, 
bounded internally by the base of the tongue. They are oval glandular 
masses, generally about as large as a hazel-nut. They are follicular in 
structure, and, when of normal size, can be just seen when the mouth is 
wide open, projecting into the isthmus faucium. On the internal surface 
are a number of mucous crypts, which open by from twelve to sixteen 
ducts, of varying size, and give the surface of the tonsils the appearance 



of almond-nuts. In the spaces between the crypts, and enclosed in the 
connective tissue, are a quantity of lymphatic glandulse. The tonsil is in 
relation externally with the internal pterygoid muscle, and corresponds 
with the angle of the jaw, or more accurately, the centre of the tonsil 
corresponds with the posterior alveolar foramen. Posteriorly, are the in- 
ternal and external carotid arteries, the first about half an inch, and the 
latter about four-fifths of an inch, from the free surface of the gland, 
with the internal jugular vein, the vagus and glosso-pharyngeal nerves. 

The muscles of the soft palate run in pairs, and under normal condi- 
tions act in concert. 

The levator palati arises from the apex of the petrous portion of the 
temporal bone and the inferior cartilaginous portion of the Eustachian 
tube; the fibres pass downward and inward to be inserted into the supe- 
rior surface of the velum, interlacing at the middle line. These muscles 
elevate the soft palate and contract the orifice of the Eustachian tube. 
The tensor palati arises from the scaphoid fossa and partly from the Eus- 
tachian tube. Its fibres pass vertically downward to the hamular process, 
where the muscle becomes tendinous, and is reflected at a right angle; it 
is separated from the process by a small bursa. The tendinous fibres ex- 
pand, and passing transversely inward interlace with the opposite muscle, 
and become inserted into the inferior surface of the velum. These mus- 
cles stretch the soft palate, and during swallowing open the Eustachian 
tube and admit air to the tympanum. The azygos uvulae (so called from 
having formerly been supposed to be a single muscle) arises from the pos- 
terior nasal spine and from the posterior portion of the mucous membrane 
which encloses the uvula; its office is to contract the uvula and draw it 
backward. The palato-glossus forms the mass of the anterior pillar of 
the fauces; it is attached superiorly to the aponeurosis of the velum, and 
below is inserted into the tongue. It is a constrictor of the isthmus. 
The palato-pharyngeus forms the posterior pillar of the fauces, and aris- 
ing in the soft palate by fibres connected with those of the opposite side, 
passes partly above and partly below the levator palati and azygos mus- 
cles. After forming the posterior pillar of the fauces the more internal 
fibres go to the mesial line, and are inserted into the pharyngeal aponeu- 
rosis, the middle become lost in the aponeurosis of the velum, and the 
external pass forward and are inserted into the posterior border of the 
thyroid cartilage. These muscles contract the isthmus, and, acting with 
the levatores palati, keep the soft palate horizontal. 

The arteries are derived from branches of the external carotid, viz. : 
the facial, the internal maxillary, and ascending pharyngeal. The ptery- 
gopalatine twig of the internal maxillary and the ascending palatine 
branch of the facial artery supply the velum, though the latter is more 
particularly distributed to the mucous membrane, muscles, and glands, 
the aperture of the Eustachian tube, and its neighborhood. The tonsillar 
branch of the facial artery supplies the tonsil, the sides of the pharynx, 
and the root of the tongue. The veins form two plexuses: the posterior, 
which is associated with the venous system of the nasal mucous mem- 
brane; and the anterior, associated with the tongue, and passing into the 
internal jugular by means of the pharyngeal vein. The lymphatics are 
arranged, as the veins, in two plexuses, corresponding with those of the 
nose and root of the tongue; they pass into glands situated at the bifur- 
cation of the common carotid, and in the region of the greater cornu of 
the hyoid bone. 

The motor nerves of the soft palate are: the motor portion of the 



THE EXAMINATION OF THE PHARYNX. 7 

lower division of the fifth which supplies the tensor palati through the 
Otic ganglion; the facial supplying the levator palati and azygos uvulse 
through the connection of its trunk with the Vidian by the petrosal 
nerves, and the palatine branches of Meckel's ganglion which supply the 
palato-glossus and palato-pharyngeus. The sensory nerves are derived 
from the second division of the fifth (its nasal ganglion), which supplies 
the anterior surface of the velum. The glosso-pharyngeal, vagus, and 
spinal accessory furnish twigs to the lateral and posterior portions of the 
soft palate and the tonsil. The chorda tympani presides over the secre- 
torv functions. 



THE EXAMINATION OF THE PHARYNX. 

The pharynx is not entirely accessible to direct vision, and the laryn- 
goscope or pharyngoscope (as the instrument has been called when em- 
ployed to examine the upper part of the throat) is requisite for the inspec- 
tion of certain parts. Further, from the situation and conformation of 
the pharynx, some regions can only be investigated by means of probes 
or by digital exploration. 

In making an ordinary examination, it is best to use the large frontal 
mirror of the laryngoscope. The patient should be directed to open his 
mouth and take a deep inspiration. The tongue should then be gently 
pressed down with a spatula, or, better still, with the handle of a laryn- 
geal mirror. Sometimes, however, this organ is so unruly, ;ind the pa- 
tient so sensitive, that the slightest pressure will produce retching. Un- 
der these circumstances a view can often be obtained, without touching 
the tongue, when the patient inspires deeply; or the tongue may be pro- 
truded, and firmly but gently grasped between the thumb and index fin- 
ger of the operator, enveloped in a towel or napkin. If the patient at 
the end of a deep inspiration then utters the vowel ;; #," the soft palate 
and uvula, as well as the pillars of the fauces, will come into view. 

The first object which attracts attention is the uvula, which in health 
is about a quarter of an inch in length, and of a pale red color, like the 
palpebral conjunctiva. From the margin of the uvula on either side at 
its base, presenting a crescentic border directed downward, is the free 
border of the velum, or curtain, of the palate. This free border, when it 
reaches the side of the pharynx, becomes continuous with the posterior 
pillar of the fauces. About three-eighths of an inch above the base of 
the uvula on either side is the inner termination of a second crescentic 
ridge, which, passing outward, forward, and downward, becomes contin- 
uous, at the side of the pharynx, with the anterior pillar of the fauces. 
Hounded by these pillars or ligaments, anteriorly and posteriorly on each 
side, are the tonsils, which in health do not project beyond the borders 
of the pillars. Between the two posterior pillars is the posterior wall of 
the pharynx, which, in common with all the other parts of this cavity, is 
lined with mucous membrane. It is a frequent seat of disease, and always 
deserves a close inspection. In health it is of a deeper red color than the 
uvula; its surface is smooth and shining, and studded here and there with 
the minute elevations of the mucous follicles. Small veins and arteries 
are also seen coursing along its surface — generally taking a vertical, or 
ooliquelv vertical, direction. 



8 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

The inferior portion of the pharynx is situated immediately behind, 
and partly below, the entrance of the larynx, and it sometimes happens 
that foreign bodies become impacted in this situation. They still more 
often become lodged in the pharyngo-larvngeal sinus, a small cavity at 
the lower part of the pharynx, on each side, bounded externally by the 
side of the pharynx, and internally by the thyroid cartilage. In some 
cases the cavity can be inspected with the laryngoscope, but in others it 
is concealed. Under these circumstances, in young subjects, or in per- 
sons with a short neck, the finger can often determine the exact position, 
and frequently effect the removal of a foreign body. In other cases, 
probes and forceps have to be employed. 

For examining the upper part of the pharynx, a small laryngeal mir- 
ror should be used. In this situation, digital examination is, however, 
also very useful. The mouth being widely opened, the operator can pass 
his index finger upward behind the soft palate, and the vault of the pha- 
rynx and its posterior wall in the upper region, as well as the orifices of 
the posterior nares and Eustachian tubes, can be thoroughly explored. 



PHARYNGEAL INSTRUMENTS. 

Probes. — Special probes are not required for the pharynx, those used 
for the larynx (hereinafter described) answering the purpose perfectly 
well. 

Brushes. — For applying solutions to that part of the pharynx which 
is visible on direct inspection, a camel's-hair pencil attached to a straight 
piece 01 aluminium wire, and fixed in a wooden handle, is all that is re- 



Fig. 1.— The Pharyngeal Spatula. 



Fig. 2.— The Pharyngeal Bistoury. 

quired. For applying remedies to the upper and lower part of the 
pharynx, the ordinary laryngeal brushes (see Laryngeal Instruments) 
answer every purpose. 

The Spatula. — This instrument (Fig. 1) resembles a long tapering 
wooden penholder, cut flat at both ends, so as to present a larger and 
smaller surface for receiving the caustic paste. It should be made of oak, 
box, or some other hard wood. It is very useful for applying caustic 
paste in cases of granular pharynx. 

TJie Bistoury. — This knife (Fig. 2) is like an ordinary sharp-pointed 
bistoury, except that the shank of the instrument should be about five 
and a half inches long, and only the last quarter of an inch should have 
a cutting edge. This is the most serviceable instrument for opening 
abscesses. 

Forceps and Scissors. — For removing growths from the pharynx, for- 
ceps and scissors are sometimes required. These instruments should be 



PHARYNGEAL INSTRUMENTS. 9 

about eight inches in length. The forceps should have sharp teeth, and 
the scissors should be slightly curved. 

The Pharyngeal Curette. — This instrument (Fig. 3) consists of a 
sharp loop of metal (somewhat resembling a curry-comb when its two 
ends are held in the hand), which can be fixed at any angle to its shaft, 
by means of a ball-joint and lock. It is extremely useful for scraping 
away the inspissated secretion in cases of follicular disease, especially 
when the affection occurs at the lower part of the pharynx, or attacks 
the epiglottis. It may also be used for tearing away adenoid vegetations 
from the vault of the pharynx. 

The Ibnsillotome. — Instruments for removing the enlarged tonsil are 
now very frequently employed, and the manner in which they came into 
use will be best understood from a short historical retrospect. 

When excision of the tonsils became a recognized method of treat- 
ment, the aid of mechanics was soon called in to effect an easy and rapid 
operation. We are indebted to an American surgeon for the first tonsillo- 
tome. The idea of this instrument appears to have been derived from 
the uvulatomes in use in this country at the end of the eighteenth century. 
Benjamin Bell, 1 in his classical work, described and figured an uvula guil- 




Pi G- 3 # — The Pharyngeal Curette. At a there is a button by means of which a small rod, 
acting through a spiral spring, bolts the hinge at b, and thus fixes the cutting loop c at the de- 
sired angle. 

lotine. It consisted essentially of a flat piece of metal with an elliptical 
opening at the distal extremity, and a broad semicircular blade, which 
when pushed forward closed the opening and cut off the uvula. 

In the year 1827 Dr. Physick, 2 of Philadelphia, not only improved the 
uvulatome, but had it made on an enlarged scale, and used it for the ton- 
sils. In modifying the instrument Dr. Physick added the stout handle at 
its lower part, which greatly facilitated the application of the instrument, 
and enabled the operator to press it firmly to the side of the throat. Five 
years after Physick's invention Fahnestock 3 devised and described an in- 
strument for excising the tonsils, which he called a sector tonsillarum. 
This instrument has been largely used in France and Germany, and in- 

1 System of Surgery. 1783, vol. iv. p. 144, Plate lii. Fig. 1. Bell himself pre- 
ferred a probe-pointed bistoury curved at the eud almost to a semicircle (same page 
and plate). Whatever instrument was used the uvula was steadily held, and the 
mouth kept open by a speculum oris or mouth dilator (Plate liv.). 

,; Amer. J. Med. Sci., vol. i. p. 202. Messrs. Tiemann&Co., of New York, state 
that they manufactured a tonsillotome about the year 1S28 or 1829, and, according to 
a letter lately placed in my hands by Dr. Beverley Robinson of New York, claim to 
have been the inventors of that instrument. 

:; Amer. J. Med. Sci.. 1832, vol. xi. p. 248. Description of an instrument, etc., etc., 
by Wm. B. Fahnestock, M.D., of Lancaster, Pa. 



10 



DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



deed throughout the whole world it is known as Fahnestock's guillotine. 
Originally it consisted of a canula terminating in a circular ring, guard- 
ing a blade of similar shape, with concentric cutting edge. On being 
placed over the tonsil the cutting ring was withdrawn by means of a 
handle attached to the canula, and the gland was divided from behind for- 
ward. As soon as the instrument became the property of the surgical 
world it underwent numerous modifications. Guersant 'altered the shape 
of the ring from circular to elliptical— a form which is much better 
adapted to the contour of the tonsil. The same surgeon, on the sugges- 
tion of Velpeau, added a small tw T o-pronged fork to the tonsillotome by a 




Fig. 4.— Physick's Tonsillotome (modified by the Author). 

mechanism which transfixed and drew the tonsil from its bed before sub- 
jecting it to the action of the cutting blade. Chassaignac 2 augmented 
the number of prongs to three, in order that the gland might be seized 
with greater firmness, and Maisonneuve 3 made further improvements in 
the instrument. 

Though Fahnestock's guillotine is almost universally used, I greatly 
prefer instruments made on the simple model of Physick, as all complica- 



1 Hypertrophic des Amygdales, Paris, 1804. 

2 Lemons sur 1' Hypertrophic des Amygdales, Paris, 1854. 

3 Bull, de la Soc. de Chir. 



PHARYNGEAL INSTRUMENTS. 



11 



ted mechanism is thereby avoided, the instrument never breaks, and can 
always be kept clean and sharp. With Physick's instrument also the op- 
erator has much more power in placing the tonsillotome in situ. The 
guillotine which I employ is the same as that of Physick slightly modified 
— so that the handle can be applied to either side of the shank. This ar- 
rangement enables the operator to use the instrument with his right hand 
for amputating either tonsil, the free surface of the blade in each case 
being directed toward the centre of the mouth. In operating, the pa- 




Fig. 5. — Fahnestock's Tonsillotome (as improved by French surgeons). 

fcient should sit facing the light, and the operator with his back to it. 
A laryngoscopist, however, will always prefer to illuminate the throat 
with the frontal mirror. The instrument being ready for use, the hilt is 
grasped in the right hand, and the aperture in the shank is placed over 
the tonsil. The surgeon, with the thumb or index finger of the left hand 
placed under the angle of the patient's jaw, then presses the tonsil in- 
ward, whilst at the same moment, with the thumb of his right hand, he 
drives home the blade of the tonsillotome. 

Professor Lucae, 1 of Berlin, has still further modified this instrument 
by adding a cup-shaped cavity over the extremity — in order to prevent 
the excised tonsil falling down the throat — and by dispensing with the 




Fig. 6. — The Author's Double Ton*illotome. When the instrument is introduced into the mouth the 
blades meet in the centre : but on grasping the two handles together, the blades are thrown out against the 
sides of the throat, and the tonsils received in the oval openings of the ton-illotomes. Amputation is then 
effected by pressing on the ring at the proximal extremity of the instrument in the ordinary way. 

wooden handle. As, however, in using Physick's guillotine the tonsil is 
always either caught in the instrument or brought forward into the 
mouth, I do not see the use of Professor Lucae's suggestion for receiving 
the tonsil. I may add that the wooden handle, dispensed with by Lucae, 
is one of the most important features in Physick's instrument, as it in- 
sures steadiness and gives power. Some years ago Messrs. Mayer & 
Meltzer made a double guillotine for me (Fig. 6), by means of which both 
tonsils can be simultaneously excised. The only objection to its use is 



'Deutsche Medic. Wochenschrift, Nos. 11 and 15, 1877. I am indebted to Mr. 
Detert, the well-known Berlin instrument maker, for a very perfect specimen of Pro- 
fessor Lucie's guillotine. 



12 



DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



that it acts equally on both tonsils, whilst it sometimes happens that 
more of one tonsil requires to be removed than of the other. 

The Uvulatome. — In speaking of tonsillotomes, it has already been 
shown that this instrument preceded, and, indeed, gave rise to the inven- 
tion of the tonsillotome. The uvulatomes, however, which were in use 
in this country at the end of the eighteenth century, were of a very rough 
construction, and it was only when the introduction of the laryngoscope 
gave a great impetus to the study of throat affections, that the modern 
uvulatome was invented. The credit of greatly improving this instrument 




Fig. 7. — The Author's Uvulatome. In the complete instrument the upper surface, with the cutting 
blade, is shown ; whilst in the other drawing the under surface, with the forceps which seize the uvula 
when cut through, is seen. 



is due to Dr. Elsberg, of New York. His instrument consisted of a cut- 
ting blade which was drawn back until placed in situ; and was then sud- 
denly discharged by touching a trigger in its upper surface. Beneath 
the blade were forceps, which seized the uvula as it was cut throu'gh. 
Finding, however, that this instrument was inconvenient in practice, as 
the strong spring imparted a great jerk to the instrument, whilst the blade 
often failed to cut through the uvula, I abandoned the spring and trigger 
arrangement and added a second cutting blade. One of the blades is 
pushed forward by the thumb whilst the other is a fixture at the distal 
extremity of the instrument. The two blades are arranged at such an 
angle that they correspond to the blades of a pair of scissors. In other 
words, as the movable blade passes down over the one that is fixed, the 
aperture receiving the uvula forms an isosceles triangle until it is oblit- 
erated by the complete closure of the blades. In using this instrument, 
the free surface of the blade should always be directed upward, and it is 
well to hold it somewhat obliquely, as by this means a tapering, instead 
of a truncated, uvula results from the operation. 



DISEASES OF THE PHARYNX. 



CATARRH OF THE PHARYNX. 

(Synonyms: Pharyngitis. Sore Throat.) 

Latin Eq. — Catarrhus pharyngis. Pharyngitis. 

French Eq. — Angine inflammatoire, superficielle, ou catarrhale. Pharyn- 

gite. 
German Eq. — Schlundkatarrh. Schlundentziindung. Halsweh. 1 
Italian Eq. — Catarro della faringe. Faringitide. 

Definition. — Acute inflammation of the mucous membrane of the 
pharynx, usually terminating in resolution, but in cachectic persons often 
causing a liability to future attacks, and leading ultimately to relaxation 
of the mucous membrane of the pharynx. 

Etiology. — Catarrh of the pharynx affects all classes, and is common 
at all ages. It is most frequent, however, in young persons. The stru- 
mous diathesis, general feebleness of constitution, and long-continued 
exposure to any influences which tend to depress the vital powers, such as 
contaminated air, bad food, impure water, &c, act as predisposing causes 
of the disease. Persons engaged in sedentary occupations, and dwellers 
in cities are more subject to the affection than those living an active 
country life. Catarrh of the pharynx is most prevalent at those seasons 
of the year when sudden changes of temperature and inclement weather 
are frequent, and the exciting cause of the malady is generally exposure 
to cold or damp. Those who have had syphilis, or been mercurialized, 
are very subject to the affection. Finally, the disease occasionally ap- 
pears to arise from some peculiar condition of the atmosphere, which 
seems to engender it epidemically. 

Symptoms. — The onset of pharyngeal catarrh is in most cases accom- 
panied by slight feverish symptoms, and a general feeling of lassitude 
and depression. These phenomena, however, may be almost entirely ab- 
sent, the first symptom complained of being a disagreeable sensation 
of dryness, and a stiffness in the throat in swallowing. As the morbid 
action becomes fully developed, considerable pain may be experienced in 
deglutition, whilst the voice becomes hoarse and partakes of a nasal 

1 The Germans do not. as a rule, use popular names for the various inflammatory 
affections of the pharynx, but employ the generic terra angina for all of them, with a 
qualifying description of the affection, thus : angina catarrhalis, a. tonsillaris, a. gan- 
grenosa. 



14 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

timbre. At the same time the patient may suffer from noises in the ears, 
and the sense of hearing may be temporarily impaired. The character 
of the symptoms depends on the extent and situation of the inflammation, 
and some writers have divided the disease into two varieties, namely, 
superior, and inferior, pharyngitis. 1 When the upper part of the pharynx 
is attacked, the swallowing and hearing are affected. On the other hand, 
should the disease be situated in the lower part of the throat, pain is 
caused by any movement of the larynx, and there is tenderness on pres- 
sure at the sides of the neck. When the whole tract of the mucous 
membrane of the pharynx is inflamed, there is a combination of all the 
phenomena. In all cases, after the first day or two, there is a considera- 
ble increase of the mucous secretion, and the patient resorts to constant 
efforts of couo'hino- and hacking, in order to clear his throat. As a rule, 
resolution soon occurs spontaneously, and at the end of a week the parts 
have regained their normal condition. In very rare cases, however, the 
disease, which at first seemed a mild catarrh, develops into an active in- 
flammation, or true pharyngitis. The symptoms are then greatly intensi- 
fied. Occasionally, the inflammation extends to the larynx, and the 
symptoms of the pharyngeal affection are lost in the more serious phe- 
nomena of oedema of the glottis. Cases, indeed, have been placed on 
record by Bamberger, 2 Rilliet and Barthez, 3 and Ruble, 4 which have been 
thought to show that acute pharyngitis may rapidly prove fatal. In 
Bamberger's cases, however, as well as in those of Rilliet and Barthez, 
there was probably suppressed scarlatina, whilst Riihle\s patient was also 
the subject of acute alcoholismus. In feeble persons, after the acute symp- 
toms have passed off, there sometimes remains a persistent delicacy of 
the mucous membrane of the pharynx, which renders the individual pecu- 
liarly susceptible to subsequent attacks of a similar nature. Oases have 
been reported by Gubler, 6 Broadbent, 6 and others, in which a simple acute 
inflammation of the pharynx caused subsequent paralysis of the veil of 
the palate. 

On inspecting the pharynx, in a case of ordinary catarrh, the mucous 
membrane is seen to be of a vivid red color, and to present a dry shining 
appearance. Some tumefaction of the pillars of the fauces and soft 
palate is almost always present. Small veins, not visible at other times, 
may be perceived, and the uvula is often slightly cedematous and elon- 
gated. When the pharynx is more acutely affected, the mucous mem- 
brane of the posterior wall of the pharynx is swollen and of a bright red 
color, looking like rich crimson velvet. Sometimes the epiglottis is also 
seen to be much swollen and congested. When the inflammation is on 
its decline, the surface of the mucous membrane is often streaked with dark 
colored viscid mucus, which adheres to the parts with great tenacity. 

Diagnosis. — Catarrh of the pharynx may be confounded with quinsy, 
but as the gland soon begins to swell when it is inflamed, the differen- 
tiation of the disease is quickly established. 

Pathology. — The affection, when slight, is merely afluxionary hypere- 
mia; Avhen severe, an acute inflammation. In all cases the vessels are 
dilated, and the severity of the affection depends on the amount of sub- 

1 Peter: Diet des Sc. Med., Paris, 1864, vol. iv. p. 695. 

2 Handbuch der Pathologic &c., Erlangen, 1855, Abth. 1. b. 6. 
2 Maladie des Enfants, Paris, 1855, p. 288 et seq. 

4 Volkmann's Sammlung Klin. Vortr., Leipzig, No. 6, s. 9. 

5 Archives Gen. de Med., 1859-60. 
f ' Lancet, 1871, vol. i. p. 808. 



CATARRH OF THE PHARYNX. 15 

mucous infiltration. The secretions contain a number of pus-cells and 
micrococci. 

Prognosis. — The great majority of cases terminate in resolution, and 
leave no troublesome after-effects. In cachectic persons, however, as 
already remarked, a permanent weakness of the mucous membrane is 
often the consequence of catarrhal inflammation, and the individual is 
rendered liable to repeated attacks of the same kind. 

Treatment. — Few persons think it necessary to take medical advice, 
on account of an ordinary pharyngeal catarrh. Confinement to the house 
for a day or two, restriction to a light diet, and the avoidance of stimu- 
lants, are the only measures required in order to allow the disease to 
undergo spontaneous resolution. A wet compress, or mustard poultice to 
the neck, a hot foot-bath, and sucking ice expedite the cure. An 
opiate, especially the tincture of opium, taken early in the day — if possi- 
ble, will generally cut short an attack. The stimulating effect of opiates 
is greatly diminished if the patient sleeps immediately after taking a 
dose. Hence the old plan of administering Dover's powder just before 
going to bed does not answer so well as that now recommended. From 
five to ten drops of laudanum generally produce the best effect. Larger 
doses act as a sedative, and instead of controlling the vascular action, 
lead to relaxation. A Turkish bath is a popular remedy, which will also 
frequently cut short an attack of pharyngeal catarrh. The disappearance 
of the local affection may, generally, be considerably hastened by pre- 
scribing a rhatany lozenge every three or four hours. After the acute 
symptoms have subsided, the mucous membrane may be braced up by 
astringent solutions. A few applications of the pigment of chloride of 
zinc or perchloride of iron (Throat Hosp. Phar.) are especially useful for 
this purpose. 

The disposition to pharyngeal catarrh is best counteracted by the use 
of a cold bath in the morning, when sufficient reaction follows. The skin 
should, if possible, be made less sensitive by the use of rough towels and 
flesh brushes, whilst hot rooms, late hours, and all habits calculated to 
relax the system, should be strictly avoided. 



UVULITIS. 

In some cases where the pharynx is inflamed, the violence of the mor- 
bid action appears to be expended on the uvula. Under such circum- 
stances this part becomes intensely red, swollen, and elongated, or it may 
be highly cedematous, and have a pale translucent appearance. It may 
attain the thickness of one of the fingers, and hang down into the sulcus, 
between the epiglottis and tongue, or even pass into the larynx and give 
rise to distressing paroxysms of dyspnoea. 

The treatment should consist of scarification or amputation. When 
the cedema is slight, the uvula may be scarified by means of a sharp- 
pointed bistoury. In a few hours after the operation the part generally 
returns to its normal size. When, however, the inflammation is very 
active, scarification sometimes only gives exit to a few drops of blood, and 
in such cases the best procedure is to amputate the end of the uvula with 
the uvulatome. A discharge of watery blood at once ensues, which greatly 
relieves the engorgement both of the uvula and the surrounding parts. 
Under these circumstances the inflammatory action usually undergoes 
rapid resolution. 



16 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

RETROPHARYNGEAL ABSCESS. 

(Synonyms: Post-Phakyngeal Abscess.) 

Latin Eq. — Abscessus post-pharyngeus. 
French Eq. — Abces retro-pharyngien. 
German Eq. — Retro-pharyngeal Abscess. 
Italian Eq. — Ascesso retro-faringeo. 

Definition. — An inflammatory swelling containing pus in the posterior 
wall of the pharynx. 

Etiology. — This is essentially a disease of childhood, though it occa- 
sionally attacks adults. The youngest children may suffer from it, and 
several cases are reported in which the disease occurred in sucking in- 
fants. 1 The male sex does not show the preponderating predisposition to 
the affection which is seen in many other diseases of the throat. Bokai * 
has collected 144: cases, and of these TS were boys, and 66 girls. It used 
to be supposed that the disease was most commonly the result of 
scarlatina, but Bokai's cases have clearly proved that the affection is 
generally idiopathic. 

The following table, abridged from that author, well illustrates the 
causes of retro-pharyngeal abscess: — 

129 cases were idiopathic, 

7 appeared in the course of scarlet fever, 

4 were due to cervical spondylitis, 

3 were of hypostatic character, 

1 was traumatic — due to a foreign body. 

In a large number of the idiopathic cases the little patients exhibited 
a scrofulous diathesis. 

In adults, abscesses, not larger than a pea, sometimes form in the wall 
of the pharynx as the result of catarrh, but these cases do not belong to 
the class now under consideration. 

Symptoms. — The inflammatory process which leads to the formation 
of an abscess behind the posterior wall of the pharynx is generally of an 
insidious nature. In most cases the symptoms are not sufficiently promi- 
nent to attract attention until the local swelling interferes seriously with 
respiration and deglutition. On inspection of the pharynx, if the abscess 
is situated high up, the mucous membrane of the posterior wall can be 
seen bulging forward, and presenting a red, smooth, and uniform sur- 
face — indicative of tension. On passing the finger (which in the case of 
children, in order to avoid being bitten, should be protected by being 
partly wrapped in a cloth) into the back of the mouth, a soft tumor can 

1 See a case by Besserer : Abscess an der hinteru Wand des Pharynx bei einem vier 
Monat alten Kinde. Schmidt's Jahrb.. 184o, p. 108 ; also a case by Winternitz : Retro- 
pharyngeal Abscess im Sauglings' Alter, Wochenschrift der Gesellscbaft der Aerzte in 
Wien, 1861, p. 241. 

* Jahrbuch fur Kinderheilkunde, 1870, Heft 1 und 2. 



RETROPHARYNGEAL ABSCESS. 17 

be perceived. When the abscess is in the lower part of the pharynx, its 
presence can be determined with the aid of the laryngoscope. 

The symptoms vary somewhat according to the position of the abscess. 
If the tumor is situated at the upper part of the pharynx, deglutition, 
especially of solids, is difficult, and the voice partakes of a nasal intona- 
tion, but the occlusion of the passage is not usually sufficient to incom- 
mode respiration. When the bulging of the pharyngeal wall occurs 
opposite the larynx suffocative attacks are likely to be frequent and may 
prove fatal, whilst swallowing may, at the same time, be interfered with 
to a serious extent. If the abscess occupies the sides of the pharynx 
there is great danger that the pus may burrow into the cellular tissue of 
the ary-epiglottic folds and thus produce oedema of the glottis and fatal 
dyspnoea. In addition to the phenomena consequent on obstruction of 
the degluto-respiratory canal, there may be stiffness of the neck, or the 
head may be drawn to one side or thrown backward, owing to exten- 
sive infiltration of the areolar tissue between the pharynx and vertebral 
column. Bokai considers that the position of the head affords a valuable 
diagnostic sign. When the abscess is situated laterally, as occurs in 
three-fourths of the cases, the head is inclined toward the healthy side. 
In some cases tumefaction of the lateral and posterior parts of the neck 
may be present, whilst contraction of the sterno-mastoid muscle may be 
so marked as to give the idea of tetanic spasm. During the first years 
of life, convulsions almost constantly accompany the disease, and Bokai 
observed facial paralysis in three cases. There is seldom, however, any 
fever in children. The symptoms of post-pharyngeal abscess often ex- 
hibit a remarkable resemblance to the phenomena of croup, for which dis- 
ease I have known pharyngeal abscess to be mistaken on several occa- 
sions. In the majority of cases, a sudden termination of all the symp- 
toms is brought about by the spontaneous bursting of the abscess, but in 
some instances the quantity of pus is so great as to suffocate the patient 
in its sudden evacuation. 1 Wendt 2 states that the abscess, when left to 
itself, may give rise to fistulous tracks which extend in the direction of 
the thoracic cavity or in the skin of the neck. 

According to Bokai, whilst idiopathic abscesses form rapidly — often 
in two days — secondary abscesses require a week or more for their devel- 
opment. Abscesses proceeding from disease of bones are still more chronic 
in their course. In conclusion, it may be observed that should the ab- 
scess depend upon caries of the vertebral column, the fact can generally 
be ascertained by noting whether pain is caused by pressure on the spi- 
nous processes of the cervical vertebrae. 

Diagnosis. — Retro-pharyngeal abscess may be confounded with croup, 
with a foreign body in the larynx, or with oedema of the glottis. With 
respect to croup, the diagnosis can easily be established by attention to 
the condition of the vocal and deglutory functions in the two diseases. 
Thus, in croup, the voice is soon extinguished, whereas in post-pharyn- 
geal abscess, it is usually only altered in intonation. Again, in croup 
there is no dysphagia, whereas in retro-pharyngeal abscess difficulty of 
swallowing is as prominent a symptom as dyspnoea. In addition, por- 
tions of false membrane being frequently coughed up in the croupous af- 
fection, the diagnosis may often be established from the appearance of 
the expectoration. The physical examination of the throat, when possi- 



1 See a case by Gaupp : Wurterab. Corr. Bl. xl. No. 23, 1870. 

2 Ziemssen's Cyclopedia, vol. vii. p. 68. 



18 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

ble, will of course determine the nature of the disease. As regards a for- 
eign body in the larynx, its presence may evoke symptoms similar to 
those of retro-pharyngeal abscess, but phonation is generally more trou- 
bled than in the latter affection. The history of the case, and the use of 
the laryngoscope, will, in many instances, complete the evidence as to the 
impaction of a foreign body in the larynx. On reference to the sympto- 
matology of retro-pharyngeal abscess, it will be seen that a veritable 
oedema of the glottis sometimes occurs through extension of inflamma- 
tion, or purulent infiltration, to the ary-epiglottic folds. The phenomena 
of the two maladies are thus occasionally combined. 

Pathology. — The origin of these abscesses is probably to be found in 
the structure of the part attacked. The abundance of glandulae in this 
situation has long been recognized, and the peculiar arrangement of the 
lymphatic vessels, as described by Dr. Edmund Simon x is still more re- 
markable. These conditions provide the nidus for the development of 
scrofulous inflammation, which is so likely to occur in young children pre- 
disposed to the disease by diathesis. The occurrence of abscess in cases 
of spondylitis is only in accordance with the phenomena commonly ob- 
served in inflammation of the osseous structures and their protecting peri- 
osteum. 

Prognosis. — A favorable termination may generally be anticipated 
when the abscess is diagnosed early and a free exit given to the pus. 
Spontaneous evacuation of the matter is also commonly followed by an 
immediate amelioration of all the symptoms. The prognosis is most un- 
favorable where the abscess has been allowed to interfere with deglutition 
and respiration for so long a time as to produce slow asphyxia and maras- 
mus. In those cases where the disease is connected with caries of the 
vertebrae, the presence of a constitutional dyscrasia, and the impossibility 
of removing the cause of the affection, render the prospect of recovery 
less hopeful. Mr. Syme, 2 however, has reported a case in which recovery 
took place after the exfoliation of the greater part of the second cervical 
vertebras; and Giinther 3 relates a still more remarkable instance in which 
the patient recovered after the removal of the third and fourth cervical ver- 
tebrae. Both these cases were probably syphilitic. In cases of spondylitis 
the malady pursues a tedious course, which exhausts the vital powers, and 
the abscess, if opened, is not unlikely to fill again. 4 As already pointed 
out, the sudden rupture of a large retro-pharyngeal abscess may give rise to 
immediate suffocation, and it must not be forgotten, as already pointed 
out, that, in infants, the formation of the pus is sometimes accompanied 
with convulsions. The prognosis may be gathered from a consideration 
of Bokai's cases. 6 The idiopathic cases are the least fatal, for out of 129 
cases only 5 proved fatal. Of the 7 patients with scarlet fever 2 died, 
and of the 4 cases of cervical spondylitis 3 terminated fatally. The trau- 
matic case also resulted in death. 

Treatment. — If pus has not actually formed, the case should be treated 
by ice, both externally and internally. If suppuration has occurred, 

1 Schmidt's Jahrbuch, vol. cvii. p. 161. 
* Edin. Med. Journ., April, 1826, p. 811. 

3 Deutsche Klinik, 1856, p. 34. (Both this reference as well as the last one are 
given by Dr. Solis Cohen: Diseases of the Throat. Philadelphia, 1872, p. 150.) 

4 In a case recorded by Abercrombie, the abscess had to be opened three times 
before the process of suppuration terminated. Quoted by Peter : Diet, des Sciences 
Med., Paris, 1864, vol. iv. p. 698. 

5 Loc. cit. 



RELAXED THROAT AND UVULA. 19 

prompt evacuation is the proper treatment. It has been suggested J that 
these abscesses may be opened with the nail of the forefinger, but it is 
better to effect free evacuation by an incision at the most dependent part 
with the laryngeal lancet. Some practitioners recommend that a trocar 
should be employed with the view of avoiding the danger of the pus flow- 
in°- into the larynx. 8 In all cases this contingency should be guarded 
against by bending the head promptly forward the moment the incision 
has been made. Whilst the local affection is being attended to, consti- 
tutional treatment will usually be necessary in order to reinvigorate the 
depressed vital powers. In strumous children, cod-liver oil, phosphate of 
iron, and iodide of potassium will generally prove useful remedies, whilst 
in infants the tendency to convulsions may often be successfully combated 
by bromide of potassium administered every three or four hours in five- 
grain doses. Finally, when convalescence is established, a change of air 
and a course of sea-bathing will, in most instances, result in the re-estab- 
lishment of the patient's health. 



RELAXED THROAT AND UVULA. 

(Synonym: Chronic Catarrh of the Throat.) 

Latin Eq. — Resolutio faucium. Uva descendens. 

French Eq. — Relachement. Atonie du pharynx. Elongation de la lu- 

ette. Chute de la luette. 
German Eq. — Erschlaffung der fauces. Verlangerung des Zapfens. 
Italian Eq. — Rilassatezza delle fauci. Ugola allungata. 

Definition. — Relaxation with slight congestion and swelling of the 
mucous membrane of the fauces and an increase in the length, and occa- 
sionally in the breadth, of the uvula. 

Etiology. — Relaxation of the throat and uvula, in by far the greater 
number of cases, probably originates in catarrh, or rather in repeated at- 
tacks of catarrh. The acute symptoms pass off, but the tissues do not 
recover their normal tone, and the result is a certain looseness of texture. 
Relaxed throat is a very common affection in variable climates, especially 
in those countries where there is a frequent combination of cold and wet 
weather. In some persons exposure to night air always brings on the 
affection. Prolonged stay in overheated rooms, on the other hand, espe- 
cially where much gas is burnt, may also give rise to it. Those who, 
whilst leading a sedentary life, are inclined to the pleasures of the table 
and a free indulgence in spirituous liquors, often suffer from relaxed 
throat. Indeed, the worst cases generally arise from the habitual abuse 
of the stronger forms of alcohol. In such cases there is often a subacute 
catarrh of the stomach, which extends upward through the oesophagus to 
the pharynx. The affection, when occurring early in the morning, is 
brought on from exposure or excess the previous evening, from hypo- 

1 Niemeyer, 7th Germ. edit. p. 519. 

2 Abelin : Retro-pharyngeal Abscess in Young Children. Nordiskt Medicinskt 
Arkiv, Stockholm, 1871, iii. No. 24. 



20 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

static congestion of the throat occurring in the recumbent position, or 
perhaps from sleeping with the mouth open and the consequent drying of 
the mucus on the surface. When the relaxed condition, however, only 
causes trouble in the evening, it then probably results from fatigue. In 
a few instances relaxed throat appears to be due to some reflex irritation, 
and women suffering from uterine complaints are often troubled with this 
affection. Relaxation of the uvula may also arise in scrofulous children 
in whom there is often a generally relaxed condition of the system. In 
a few cases an abnormal length of the uvula has been observed to be a 
congenital malformation. Paralysis of the veil of the palate, consequent 
on progressive bulbar disease or diphtheria, also produces a falling of this 
part. 

Relaxation of the pharynx rarely leads to any serious alterations in 
structure, and, though it may persist for years, seldom gives rise to any- 
thing more than a temporary inconvenience. 

ISymjjtoms. — On waking after a night's rest, a person affected with re- 
laxed pharynx experiences a peculiar fulness and stiffness of the throat, 
often accompanied with a disagreeable sensation, as if due to the pres- 
ence of a foreign body. The throat feels dry and parched, and repeated 
efforts are made to dislodge the supposed cause of irritation. These 
symptoms may last for days together, but they often subside as soon as 
the patient has taken a sip or two of hot coffee or tea. The examination 
of the throat sometimes affords only negative results, but in most cases 
the fauces are seen to be relaxed and slightly swollen, the whole of the 
palate dependent, and the uvula elongated. There is also generally a 
varicose condition of the smaller veins. Sometimes the surface of the 
pharynx has a peculiar pellucid appearance from being covered by a trans- 
parent film of mucus. When the uvula is much affected the symptoms 
are more troublesome and very persistent — a distressing, tickling cough 
often continuing during the whole day. In the worst instances the uvula 
may be so much lengthened as to be drawn into the larynx in inspiration. 
This event usually occurs when the patient is sleeping on his back, and 
he awakes suddenly with a suffocative attack. In cases of this kind the 
abnormal condition of the organ often produces nausea and vomiting by 
irritating the fauces and base of the tongue. On inspection the relaxed 
state of the uvula can at once be perceived. The mucous membrane and 
submucous tissue are the structures affected, there being usually no in- 
crease in the bulk of the azygos uvula? muscle. The mucous membrane 
sometimes forms a kind of opaline vesicle at the extremity of the uvula, 
and from this point a constant dripping of watery mucus may take place. 
It must not be forgotten, however, that considerable elongation of the 
uvula may sometimes exist without giving rise to any marked subjective 
symptoms. 

Pathology. — The blood-vessels are dilated and gorged, and the tissues 
generally either swollen from serous infiltration, or thickened by semi- 
organized products. The glanduke are usually both dilated and hyper- 
trophied. 

Prognosis. — A cure can nearly always be effected, if the patient avoids 
the causes of the disease, and submits to proper treatment. 

Treatment. — The various exciting causes already referred to must be 
carefully avoided, and the patient must live in a dry and bracing atmos- 
phere. If there be any hepatic congestion, or irregularity of the bowels, 
a glass or two of Friedrichshall or Pullna Bitter Wasser, should be taken 
early in the morning. If the affection be slight, the free use of a gargle 



ULCERATED THROAT. 21 

of chlorate of potash, night and morning, will sometimes quickly relieve 
the unpleasant symptoms. Mildly astringent lozenges, such as rhatany 
and kino (Throat Hospital PhaF.), taken four or five times a day, are 
very useful. When the affection is obstinate the local application of as- 
tringents, such as solutions of perchloride of iron ( 3 j- ad 3 j.) or chloride 
of zinc (grs. xxx. ad 3 j.), combined with the internal use of tonic reme- 
dies, will sometimes effect a cure. If, however, the uvula is much elon- 
gated and occasions troublesome symptoms, it should be shortened. Ab- 
scission of this fold of mucous membrane has been practised from a very 
early date. 1 The ordinary method is to cut off a small portion with a 
pair of scissors, whilst the extremity of the uvula is held with forceps. 
The operation is, however, more efficiently and rapidly performed with 
the aid of the uvulatome, in the manner already described. Occasionally 
severe and continuous hemorrhage follows the little operation, but it can 
always be checked by slowly sipping a teaspoonful or two of the tanno- 
gallic gargle of the Throat Hospital Pharmacopoeia. The immediate 
effect of the operation is generally to cause a painful sore throat. The 
patient can only swallow liquids, and even these cause pain. There is, 
indeed, sometimes odynphagia of the most severe character. Occasion- 
ally the pain extends to the ears, and severe spasmodic contractions of 
the pharynx may take place. In some instances, on the other hand, the 
operation does not give rise to any trouble, and in most cases the pain 
passes off in a day or two. The soreness of the throat may be greatly 
relieved by frequently sucking a marshmallow lozenge (Throat Hosp. 
Phar.). The bland substance of the lozenge adheres to the wound, and 
forms a protecting covering. The wound soon heals, and the advantages 
which result from the removal of the part are in most cases almost imme- 
diately experienced. The irritating fits of coughing at once subside, and a 
very great improvement often takes place in the patient's general health. 
In cases ichere there is any follicular disease of the throat, it is most im- 
portant to cure that affection before the uvula is amputated, as owing 
to the after-pain caused by the removal of the uvula, patients will not 
submit to any further treatment, when they have recovered from the op- 
eration. Hence the patient remains uncured, and the operation, and he 
who performed it, are brought into discredit. 



ULCERATED THROAT. 

Latin Eq. — Fauces ulcerosa. 
French Eq. — Ulcerations de la gorge. 
German Eq. — Geschwiirige Pharynxentziindung. 
Italian Eq. — Angina ulcerosa. 

Definition. — A superficial ulceration of the fauces, due to slight sep- 
ticaemia. 

Etiology. — Ulcerated throat is an affection often encountered in de- 
bilitated persons exposed to the influence of septic poisons. During epi- 
demics of anginose scarlatina, or of diphtheria, this form of sore throat is 

1 See Aretaeus, Tie pi alritav Kal o-qixsiuv, /c.t.A., LI. cap. viii. 



22 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

frequently observed amongst the attendants of the sick. The disease 
generally manifests itself in persons who have been long exposed to un- 
healthy influences, or in those who have become weakened from constant 
watching, loss of rest, and insufficient exercise. Students who are dili- 
gent in hospital practice, and those passing much time in the dissecting 
room, are peculiarly liable to ulcerated sore throat, called by the Ger- 
mans angina nosocomii. 

Symptoms. — The first symptom of ulcerated sore throat is odynphagia, 
which is especially noticed in swallowing the saliva. The throat feels 
stiff and swollen, the tongue is furred, and the breath offensive. The 
pulse is generally weak, and the temperature slightly raised. There is 
great loss of appetite. Though the patient feels drowsy he is often una- 
ble to sleep, and there is a sense of general malaise and lassitude, and 
sometimes shooting pains in the limbs are experienced. The patient also 
frequently suffers from a splitting headache. On examination it will be 
seen that the tonsils are somewhat swollen and congested, and that there 
are one or more small, white, superficial ulcers on the surface of the ton- 
sils or fauces. The ulcers are generally round or oval, and vary in size 
from that of a millet seed to a shilling, but they are sometimes even 
larger; when there are several ulcers they show no disposition to become 
confluent. 

Diagnosis. — The conditions under which the disease arises, and its 
rapid development facilitate its diagnosis. The ulcers are seldom covered 
by any deposit or membrane, and there is generally no difficulty in deter- 
mining the nature of the affection. 

Pathology. — The disease is probably a low form of inflammation, in 
which there is a slight alteration in the constitution of the blood. The 
nutrition of the part is impaired, and molecular death takes place. 

JPrognosis. — This is always most favorable. 

Treatment. — The patient should at once be removed from the insalu- 
brious surroundings, and have the advantage of healthy atmospheric con- 
ditions. The bowels should be evacuated by the administration of a miid 
aperient, but, on account of the generally asthenic nature of the affection, 
mercurial cathartics are to be avoided. To combat the fever and the 
symptoms of septicaemia, quinine and ammonia should be administered as 
soon as the tongue has cleaned; and to relieve the local condition, anti- 
septic gargles (Throat Hospital Phar.) are often useful, especially those 
containing chlorate of potash, permanganate of potash, borax, carbolic 
acid, or chlorinated soda. Mildly astringent lozenges, such as rhatany or 
kino (Throat Hospital Phar.) may frequently be used with advantage. 
In some cases, however, owing to the great swelling, gargling and suck- 
ing lozenges are attended with so much pain that we must resort to some 
other plan of local medication. Under these circumstances the use of in- 
halations sometimes gives relief, and a soothing vapor, such as the Vapor 
Benzoirii or Vapor Conii (Throat Hospital Phar.) may render good ser- 
vice. Warm inhalations are especially indicated when the inflammation is 
slight and circumscribed. On the other hand, when the inflammatory 
process is very acute, sucking ice answers best. Ice, applied in a bladder 
to the head, also at once removes the cephalalgia, so often present. The 
patient should be fed on bland and nutritious fluids, and a few glasses of 
good wine, well diluted with water, will be of service. 

Under suitable treatment the patient rapidly improves, and convales- 
cence is generally thoroughly established in a few days. 



GRANULAR PHARYNGITIS. 23 



GRANULAR PHARYNGITIS. 



(Synonyms: Follicular Pharyngitis. Granular Pharynx. Cler- 
gyman's Sore Throat. Chronic Pharyngitis.) 

Latin Eq. — Dysphonia eiericorum. 

French Eq. — Angine glanduleuse. Angine granuleuse. Angine papil 

laire. Pharyngite glanduleuse. Pharyngite granuleuse. 
German Eq. — Chronischer Pharynxkatarrh. Chronischer Pharyngitis. 
Italian Eq. — Faringitide cronica. 

Definition. — Chronic inflammation of the follicles of the pharynx oc- 
curring in two forms — the hypertrophic and the exudative. In the hyper- 
trophic form the diseased glands, or the epithelial structures, become en- 
larged, and appear as elevated granular bodies on the surface of the mu- 
cous membrane. In the exudative form the glands give exit to a white, 
inspissated secretion, which projects from the point of issue, or adheres 
in patches to the mucous lining of the pharynx. What relations — if any 
— the two forms bear to each other has not been determined. 

History. — The existence of this disease was scarcely recognized until 
1846, when Chomel ' published some remarks on a special state of the 
pharynx, which he called V angine granuleuse. Nevertheless, as early as 
1741, Van Swieten 2 had mentioned in his commentary on Boerhaave that 
the " mucous crypts " of the pharynx, larynx, and oesophagus, w T hen ob- 
structed and swollen, gave rise to troublesome symptoms, and to defi- 
ciency in the mucous secretion. The monograph of Chomel had scarcely 
been perused by the body of the profession when Horace Green, 3 of New 
York, published a treatise on the same subject based on careful observa- 
tions of the malady during a period of more than six years. He gave a 
good description of the disease under the name of follicular disease of 
the pharyngo-laryngeal membrane. In 1851 Buron 4 read a thesis on 
chronic pharyngitis, confirming the observations of Chomel, and in 1857 
Gueneau de Mussy 5 still further elucidated the subject in the most 
systematic and exhaustive monograph that has yet appeared. The litera- 
ture of the disease is now extensive, but although the objective and sub- 
jective symptoms have been well described, there is still considerable 
divergence in the views of the various authors, especially with respect to 
the pathology of the affection. The morbid anatomy of follicular disease 
of the degluto-respiratory tract has not yet been studied sufficiently 
thoroughly to enable us to determine the exact relations which the various 
appearances presented during life bear to each other. 

Etiology. — The causes of follicular pharyngitis are predisposing and 



1 Gazette Med icale, 1846, p. 310. 

2 Comment, in H. Boerhavii Aphor. de Cognosc. et Cur. Morbis, Lugduni Bat. r 
1741, vol. ii. p. 575. 

a A Treatise on Diseases of the Air-Passages, &c, New York, 184G. 

4 De la Pharyngite Ohronique, These de Paris, 1851, No. 203. 

5 Traite de 1' Angine Glanduleuse, Paris, 1857. 



24* DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

exciting. The strumous, gouty, and rheumatic diathesis ' predispose to 
the disease. Heredity is considered by Green a to be an influential factor 
in its production. A majority of cases are met with between the ages of 
twenty-five and thirty-live years, 3 but the affection frequently shows itself 
much earlier. Thus Gueneau de Mussy 4 mentions instances occurring 
in children under fifteen years, and I have met with the disease in chil- 
dren of eight, six, and even three years of age. Amongst adults the 
malady is more common in the male than in the female sex — a fact which 
can perhaps be explained by the much greater exposure of men to the 
exciting causes. The delicate state of the mucous membrane of the 
throat, which often remains after severe attacks of influenza, scarlatina, 
measles, and small-pox, sometimes appears to render the individual liable 
to follicular disease. The most potent of all the exciting causes of granu- 
lar pharyngitis is overexertion of the voice. In those of sound constitu- 
tion and good muscular development considerable exercise of the vocal 
organ is not followed by any bad effects, but, on the contrary, such ex- 
ertion rather acts as a local tonic. When, however, the vital powers are 
naturally feeble, and the bodily conformation ill-adapted for prolonged 
and forcible effort, the overexertion of any organ invariably impairs the 
activity of its functions and produces disease. 

A very large proportion of the cases of granular pharyngitis which 
have come under my notice have been amongst those using the voice, 
such as the clergy, singers, hawkers, and costermongers. In almost every 
instance the evidence of constitutional delicacy is well marked, and most 
of the patients present an anaemic appearance. In nearly all cases where 
the origin of the affection cannot be attributed to overuse of the voice, 
the immediately exciting cause is exposure to cold. A series of three 
successive causes can thus be laid down as being in most instances con- 

1 Since Gueneau de Mussy published his work, already referred to, French physi- 
cians have regarded the herpetic diathesis as a very frequent cause of the affection. 
The term " herpetic " is, however, so vague that I do not feel myself justified in mak- 
ing use of it. The most complete definition of the diathesis and its manifestations is 
given by Bouchut et Depres in their Dictionary of Medicine. In the following ex- 
tracts the terms, diathese dartreuse, diatliese herpetique, and herpetisme, are synony- 
mous : — 

Dartes. — " Les maladies de la peau qui dependent d'une diathese autre que la 
syphilis, la scrof ule, le rhumatisme ou l'alteration du sang par les poisons et les virus 
sont des dartres. La disposition de l'organisme qui favorise l'apparition des dartres 
constitue V herpetisme. 

" Pendant la jeunesseles dartres (furfuracees, papuleuses, vcsiculeuses, pustuleuses, 
squameuses, tuberculeuses) occupent la peau, mais par suite d'un traitement reper- 
cussif ou par le fait des changements organiques operes par l'age elles se portent a, 
l'interieur sur les muqueuses, et engendrent les angines et les bronchitis chroniques, 
Temphyseme, l'asthme, la gastralgie, la diarrhee, la dyspepsie, le flux vaginal et une 
foule de maladies chroniques." 

Herpetisme. — " La constitution de certains sujets favorable au developpement des 
dartres ou des maladies internes dues au principe dartreux, est ce qu'on appelle herpe- 
tisme. C'est une diathese qui produit a, l'exterieur sur la peau, des vesicules, des pus- 
tules, des squames, des bulles, et a I'interieur des catarrhes muqueux chroniques d'ou 
resultent un grand nombre de maladies viscerales graves." 

Herpetique. — " Qui est de nature dartreuse. Ainsi on dit qu'un individu affecte d6 
dartres est atteint de la diathese herpetique." 

The words dartre, tetter, and sitter are ail supposed to be derived from the tremu- 
lous or twitching movement to which skin diseases sometimes gives rise. They seem 
too vague to be made the basis of a diathesis, which can only be formulated as a nega- 
tion (see dartres above), but which is so comprehensive that it includes nearly all skin 

2 Op. cit. p. 159. 3 Ibid. p. 165. 4 Op. cit. p. 18. 



GRANULAR PHARYNGITIS. 25 

eerned in producing the disease, viz.: — 1. Constitutional predisposition 
(this includes any cachexia, but especially the strumous diathesis); 2. 
Overexertion of the voice (with consequent weakening of the mucous 
membrane of the throat); 3. Exposure to cold — the latter being the most 
immediate, though not the most potent, of all the causes. In addition, 
the application of any irritant to the already weakened mucous membrane 
is capable of exciting the morbid action of the glandular apparatus. My 
own experience does not, however, coincide with that of Green 1 and 
Gueneau de Mussy 2 with respect to the use of tobacco. It is possible 
that, in certain persons, excessive smoking may cause congestion of the 
mucous membrane of the throat, and sometimes tend to produce a block- 
ing up of the mouths of the follicles, but the abuse of tobacco more often 
leads to simple chronic relaxation. It has been asserted that those who 
are compelled to breathe constantly a tainted atmosphere, or to reside in 
a damp climate, are, cceteris 2W>'ibi(S, most liable to be attacked by this 
malady; and that those who are subjected to the presence of irritating 
gases or powders in the atmosphere, as is the case in chemical works, 
metal factories, cotton mills, coal mines, etc., are prone to the disease. 
I have met with many cases in which the etiology could not be arrived at. 
Syn^toms. — Patients affected with follicular pharyngitis do not, as a 
rule, experience any painful sensations at the outset of the disease. The 
first symptoms are generally confined to a sense of stiffness and dryness 
in the throat, and a tickling cough. Should the patient, however, be 
subject to severe fits of coughing, he almost always complains that " it 
hurts him to cough; " and, on questioning him more closely, it can be 
ascertained that each impulse of coughing causes a feeling of tenderness 
and soreness about the upper part of the larynx and the arch of the 
palate. Amongst public speakers or singers the first symptoms which 
attract the attention of the patient, and generally occupy his mind to the 
exclusion of all other phenomena attendant on the disease, are hoarse- 
ness and a loss of power over the voice. As the morbid condition of the 
follicles increases, their functions are interfered with. Dryness and 
soreness of the throat supervene, causing the patient great inconvenience, 
and constituting what has been called pharyngitis sicca. An insupport- 
able sense of pricking and heat is often felt in the pharynx, whilst a 
harsh, dry cough, accompanied by repeated hawking efforts, simulates 
pulmonary phthisis. The larynx almost constantly feels obstructed, and 
the sufferer is led to make continual fruitless attempts to clear the throat. 
Small quantities of viscid mucus are occasionally expectorated, whilst the 
strain of excessive coughing sometimes causes the sputa to be tinged with 
blood. In the most pronounced cases of granular pharyngitis the dis- 
eased condition of the follicles extends to the nasopharyngeal space and 
posterior nares, to the front of the soft palate and uvula, and to the 
upper part of the larynx and oesophagus. As a consequence, therefore, 
of the implication of these parts the malady is sometimes accompanied by 
impairment of the senses of hearing, smell, and taste, in proportion as the 
orifice of the Eustachian tube, the pituitary membrane, or the mucous 
covering of the palate participate in the morbid process. Hoarseness and 
feebleness of voice result from the larvnx beinsr involved, and the g-eneral 
soreness and stiffness of the parts concerned in the production of speech 
cause a marked hesitation and effort in articulation. When the upper 
part of the oesophagus or the epiglottis becomes affected considerable 



1 Op. cit. p. 174. 2 Op. cit. p. 28. 



26 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA 



pain in swallowing usually results, and some patients are reduced to the 
necessity of subsisting altogether on liquid food. The symptoms are, as 
a rule, much more marked in the exudative than in the hypertrophic 
form of the disease. As Peter * remarks, however, a considerable amount 
cf enlargement of the follicles of the pharynx, etc., may exist, and, at the 
same time, give rise to so little inconvenience •that the patient may be 
quite unconscious of there being anything unusual in the condition of his 
throat. 

The objective symptoms of both forms of follicular pharyngitis are 
most characteristic, and at once strike the observer on making an inspec- 
tion of the part. In the hypertrophic form of follicular disease, the 
locality of the throat first affected is the posterior wall of the pharynx. 
in the early stages of the disease the mucous membrane in this situation 
may be seen to be dotted with small elevations, about the size of a millet- 
seed, entirely isolated from each other. As the disease advances, these 
granulations increase in number until they become packed so closely to- 
gether as to give a reticulated appearance to the part, and finally they 
coalesce and form broad, flattened elevations, or long ridges running in 
various irregular directions over the mucous membrane. In most cases 
injection ci the superficial veins of the pharynx is present, and these ves- 
sels can often be seen pursuing a tortuous course along the furrows, or 
forming a kind of net-work round the elevations. As the disease ad- 
vances the granulations become developed on the adjacent parts of the 
^aucec a^d tonsils, and sometimes give rise to hypertrophy of these 
g^aadu Examination by means of the rhinoscopic and laryngeal mirrors 
wi 11 be recnr'red in order to estimate how far the naso-pharyngeal cavity, 
jlie 'ower r>art of the pharynx, and the larynx are implicated in the mor- 
oil nrocess. Coincident with the appearance of these several phenomena 
there is a ] ways considerable perversion of the secretions of the pharynx. 
This derangement is almost always on the side of deficiency. 

In the exudative form of follicular disease, the affection generally 
commences in the tonsils or in their immediate neighborhood, and ad- 
vances to the posterior wall of the pharynx, the back of the tongue, the 
epiglottis, and the interior of the larynx. In health the secretion of the 
follicles appears to the naked eye as a watery transparent fluid, but if the 
follicles become acutely inflamed their secretion (probably from increase 
of the corpuscular elements) becomes milky in color and consistence. 
This condition is constantly seen in follicular tonsillitis. If the inflam- 
mation is less acute and more persistent, the milky secretion becomes in- 
spissated, and leads to the formation of the caseous deposits so charac- 
teristic of the disease. In the earliest period, the throat is seen to be 
dry and glistening, whilst the orifices of the follicles are bright red, and 
>;ne intervals of mucous membrane between them generally slightly hyper- 
emia Later on, however, the diseased follicles discharge a morbid secre- 
tion, and viscid mucus is often seen adhering in patches to the follicles, 
or filling up the intervals between them. On pressing the enlarged fol- 
licles this exudation may be seen to issue from them, generally by a single, 
minute aperture, situated near the centre of the elevation. The secre- 
tion may have the cheesy character already described, or may resemble 
fc&€ matter which can be pressed out 01 che follicles of the skin of the 
mose or face when affected with acne. Sometimes the secretion, after ex- 
uding from the follicles, adheres to the part in small white patches of 



• incu Jet. '-Sciences 'Mod. , vol. if. o. 749 



GRANULAR PHARYNGITIS. 27 

irregular shape, about l-16th of an inch in diameter, or hangs like a thread 
from 1 -20th to l-8th of an inch in length from the point of exit. On in- 
spection, under these circumstances, the pharynx is seen to be dotted at 
numerous points, but especially about the pillars of the fauces and tonsils, 
by patches of white accretion resembling, in color, consistence, and odor, 
decomposing cream cheese. According to my experience, ulcerations of 
any size or depth rarely occur as a direct consequence of follicular disease 
of the pharynx, and, when present, are generally due to some associated 
disease, such as syphilis or phthisis. 1 Sometimes the secretion is chalky 
in appearance, and calcareous in composition. Unlike the hypertrophic 
form of the disease, instead of there being any disposition to increase of 
tissue, the tendency appears to be of an opposite nature — i. e., toward 
an atrophy of the structures and enlargement of the cavity of the 
pharynx. The case reported by Gueneau de Mussy, 2 in which calcareous 
matter could be pressed out of the follicles situated in and about the ton- 
sils, seems clearly to belong to the exudative form of the disease, and 
although unique in that writer's experience, is a phase of the malady 
often met with in this country and in Germany. s A general relaxation 
and loss of tone of all the structures of the pharynx soon results from 
the disease, and the uvula becomes in some instances so much elongated 
as to rest on the base of the tongue, or even to hang down into the 
larynx. 4 Titillation of the base of the tongue and epiglottis by the 
elongated uvula, is one of the commonest factors in the production of the 
incessant, tickling cough. 

Pathology . — The pathological varieties of this affection have not as 
yet been sufficiently worked out to enable us to determine the relations 
between the two kinds of granular disease. Whether the exudative form 
is the result of degenerative changes, in glandulae previously hyper- 
trophied, or whether the exudation is the product of a simple morbid 
secretion, is at present unknown. The nature, differences, and extent of 
the morbid alterations in the mucous membrane and its secretory glands 
have yet to be elucidated, but the tendency of investigation is to show 
that the hypertrophic and exudative diseases, though they may coexist, 
are totally distinct affections, differing in their symptoms, course, and 
pathology, and requiring, as is shown in this article, totally different 
treatment. According to Stoerk, 6 in the hypertrophic form the granula- 
tions consist of large, nearly round, swollen, epithelial cells, the layers of 
hard compressed cells or flattened scales which usually cover and protect 
the surface having disappeared. The morbid changes are in fact more in 
the epithelium than in the follicles. In a case of exudative disease re- 
ported by de Mussy, where a microscopic examination was made by Drs. 
Sappey and Robin, the principal histological changes noted were as fol- 
lows: — The tubules of the follicles were found considerably enlarged, 
both as regards the diameter of their cavity and the thickness of their 
walls. In the follicles which were most hypertrophied and indurated, 
small calcareous concretions were discovered, composed principally of 

1 Green considers ulceration as frequent : Op. cit. pp. 51 — 180 et seq. 
* Op. cit. p. 189. 

3 Wendt : Ziemssen's Cyclopaedia (German edition), vol. vii. part I. p. 266. 

4 See a case depicted by Dr. Green in which suffocation nearly occurred on several 
occasions from the end of the uvula being drawn into the larynx during inspiration : 
Op. cit. p. 270. 

5 Klinik der Krankheiten des Kehlkopfes. Stuttgart, 1876, p. 114. 

6 Op. cit. p. 87. 



28 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

carbonate of lime. In some of the glands these concretions were numer- 
ous, and packed together so closely as to present, when detached, a crystal- 
line appearance, owing to their surfaces having been moulded into 
polyhedral, faceted figures. On the other hand, the cellular tissue con- 
necting the secretory tubules and the epithelium lining their internal 
walls presented but little departure from the normal condition beyond a 
very slight thickening. With respect to the vessels of the hypertrophied 
follicles, the capillaries showed no perceptible change, but on the whole 
the diseased glands appeared to be less vascular than in the healthy 
pharynx. 

The cheesy secretion consists of the debris of epithelial cells, of mole- 
cules, and oil globules. 

Diagnosis. — The recognition of follicular pharyngitis, whether hyper- 
trophic or exudative, presents no difficulty, and the condition can scarcely 
be confounded with any other disease. In cases where the cheesy exuda- 
tion is very abundant and coats the surface of the pharynx, a person who 
had never seen an example of either disease might suppose that diphtheria 
was present. As a rule, however, the discharge in the follicular disease 
adheres to the surface of the mucous membrane in small isolated patches, 
and is very different to the tough, membranous exudation which occurs 
in the more serious malady. 

Prognosis. — I cannot at all acquiesce in the opinion of Dr. Green, 1 
that pulmonary phthisis can ever owe its origin to granular pharyngitis. 
Nor is it more likely that when the follicles of the oesophagus become im- 
plicated in the morbid action, malignant disease of the gullet can ever be 
a direct consequence. 2 Phthisis, however, is sometimes associated with 
granular pharynx. Most cases of follicular disease of the pharynx get 
well under appropriate treatment, i.e., as far as the troublesome sensa- 
tions are concerned, but with respect to the vocal function, the prognosis 
is not always so favorable, especially as regards public speakers, sing- 
ers, etc., if the disease has existed many years. The vocal organ zs ex- 
tremely likely to remain permanently weakened, at least to such an extent 
as to interfere with its constant professional use. The exudative variety 
of the disease is much more difficult to eradicate than the hypertrophic 
form. 

Treatment. — As many writers have a strong belief in the purely dia- 
thetic character of the local phenomena attendant on granular pharyngitis, 
the treatment prescribed is often almost entirely limited to constitutional 
measures. In my experience, 5 however, topical applications have been 
so generally successful that I cannot but conclude that the local medica- 
tion of the affected parts is the essential factor in treatment. The two 
forms of the disease as described in this article require a different method 
of topical treatment. When the hypertrophic form alone is present, no 
remedy is so productive of good results as the London paste (Throat 
Hosp. Phar.). This caustic should be applied to each granulation sepa- 
rately, but only two or three of the elevations, and in some cases only one 
spot, should be touched on the same day. The mode of procedure is as 
follows: — Having made the powdered preparation into a thick cream by 
rubbing it up with a sufficient amount of water, a small quantity of the 
caustic is applied to the desired part with the pharyngeal spatula (page 8). 



1 Op cit. p. 118. ° Ibid. p. 129. 

3 See also Kunze : Compendium der praktischen Medicin. p. 218 ; Niemeyer : 
Pathologie u. Thcrapie, vol. i. p. 500 ; and Wendt : Op. cit. p. 278. 



GRANULAR PHARYNGITIS. 29 

Immediately after the application has been made the patient should be 
directed to gargle and wash out the throat with cold water, so as to 
remove any particles of the caustic that may remain adherent to the part 
touched. The London paste should be persevered with in this way until 
all the granulations are destroyed. As a rule, one touch of the paste is 
sufficient to remove a granulation, and establish a healthy action in the 
part; but if the elevation be very large, or if there be many separate 
raised spots, a number of applications may have to be made. It is 
scarcely necessary to observe that it is most important not to set up ex- 
tensive inflammation by using the paste too freely on any one occasion. 
In some persons the application may be made every day, whilst in others 
twice or three times a week will be sufficient. In the intervals milder 
remedies can often be used advantageously — such as the pigmenta of 
perchloride of iron or chloride of zinc (Throat Hosp. Phar.); and when 
there is much irritation of the fauces, consequent either on the disease or 
on the action of the caustic, a sedative inhalation of benzoin or hop 
(Throat Hosp. Phar.) is beneficial. 

It has been recommended that the elevations should be destroyed by 
galvanic, 1 or actual, 2 cautery; but as the granulations can be readily got 
rid of by a simple escharotic, complicated processes and alarming methods 
had better be avoided. 

As regards the exudative form of follicular pharyngitis the local treat- 
ment can be carried out without having recourse to so strong a caustic as 
the London paste. My practice in such cases is first to scrape the mucous 
membrane wherever the white spots appear with the " pharyngeal cu- 
rette," already described (p. 9), and, having thus cleared away the secre- 
tion, to apply the solid stick of nitrate of silver — which should be care- 
fully pointed for the purpose — to each spot which discharges an abnormal 
secretion. 

Whilst the local treatment is being accomplished, internal remedies 
calculated to give tone to the vital powers and improve the general 
health of the patient should be administered. Struma, anaemia, syphilis, 
etc., must be met by the exhibition of cod-liver oil, iron, iodide of potas- 
sium, etc. After the topical measures have been completed, the per- 
manency of the cure may usually be established by change of air, residence 
at the seaside for a month or two when the season is suitable, or by di- 
recting the patient to use the arsenical waters of Mont Dore, the hot sul- 
phur springs at Aix-les-Bains, Cauterets, or Weilbach, or the saline 
waters of Ems. By a course of mineral waters and sprays the local weak- 
ness and diathetic condition are both generally greatly ameliorated. In 
the case of strumous children, benefit often results from a stay at Wood- 
hall Spa, whilst the bracing air of Harrogate, Tunbridge Wells, and sim- 
ilar places often proves invigorating. 

1 Michell : Deutsche Zeitschrift fur Chirurgie, ii. Bd. 2 Heft. 

2 Foulis : Glasgow Med. Journ., October, 1877. 



30 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



PUTRID SORE THROAT. 

Latin Eq. — Cynanche maligna. Angina putris. 
ErencJi E<j. — Angine gangreneuse. Angine maligne. 
German Eo. — Angina maligna oder gangrenosa. 
Italian Ej. — Angina maligna. 

Definition. — Primitive gangrene of the pharyngeal mucous membrane, 
constituting an affection per se, and originating independently of any 
other malady, such as diphtheria, scarlet fever, etc. 

History. — As Peter } well observes, the history of this affection may 
be divided into three periods. First, the ancient period, when a belief 
founded principally on the vague descriptions of Hippocrates and Are- 
treus, prevailed that the disease was a common one, whilst in fact almost 
all the reported examples were cases of diphtheria. Secondly, the period 
of Bretonneau, subsequent to 1821, when the researches of that observer 
proved that the so-called cases of gangrene were only instances of diph- 
theria, and that a true gangrenous lesion was rarely, if ever, present in 
that disease. As a consequence of this discovery a majority of the pro- 
fession were led to affirm the non-existence of a primitive gangrene of the 
throat. Thirdly, the contemporary period, in which, owing mainly to the 
observations of Gubler 2 and Trousseau, 3 the existence of the malady has 
been clearly recognized, whilst the conclusion has been arrived at that the 
disease is an extremely rare one. 

Etiology. — Malignant sore throat appears always to be the result of 
blood-poisoning. It sometimes commences as a severe inflammation, 
which quickly leads to gangrene; whilst at other times it is gangrenous 
from the commencement. I have met with several instances of the in- 
flammatory form, but only one case in which gangrene was the initial 
local manifestation. Trousseau remarks that " It has for its fundamen- 
tal character mortification of the mucous membrane of the pharynx, which 
takes place at the first onset of the malady, and occasionally spreads to 
the cheeks and lips. The disease is comparable to gangrenous stoma- 
titis." 

Sympto?ns. — In some instances sthenic phenomena, with considerable 
fever and local inflammation, indicate the advent of the malady, but in 
most cases the symptoms are adynamic from the first. A premonitory 
stage is not always present, and soreness of the throat, rapidly becoming 
intensified, is often the first symptom which disturbs the feelings of the 
patient. The gangrene frequently supervenes with great rapidity, so that 
in two or three days a portion of the pharyngeal mucous membrane may 
be sphacelated. In some cases there is considerable swelling of the cer- 
vical glands, but this lesion is not invariably present. As the morbid pro- 
cess becomes fully developed, it is in all instances accompanied by a re- 
markable prostration of the vital powers. A state of collapse comparable 
to that which occurs in cholera indicates the intensity of the blood- 

1 Diet, des Sciences Medicales, Paris, 18G6, vol. iv. p. 700. 

2 Archiv. Generates de Mecl., 1857, vol. ix. p. 513. 

3 Clinique Med. de l'Hotel-Dieu, Paris, 18G5, p. 324. 



PUTRID SORE THROAT. 31 

poisoning; there is great loss of body heat, and the pulse soon becomes 
slow and infrequent. Thus in one of Gubler's ' cases the contractions of 
the heart sank to fifteen per minute. The extremely feeble condition of 
the circulation is shown by the pallor, coldness, and bluish discoloration 
of the skin, especially of the extremities. The expression of the face is 
strikingly altered and pinched. The patient generally dies from syncope, 
the intelligence often remaining intact to the last. In some cases, how- 
ever, the sufferer becomes comatose, and occasionally symptoms of pro- 
found lesions of the thoracic or abdominal viscera are manifested. Should 
the lungs be affected copious haemoptysis results; whilst, if the gangre- 
nous process invades the alimentary tract, an abundant, fetid diarrhoea 
supervenes, which all remedies are powerless to check. Occasionally a 
general tendency to hemorrhage is manifested, and a persistent bleeding 
occurs simultaneously from the lungs, bowels, nose, mouth, and even 
under the skin, which becomes covered with petechia?, and ultimately 
sphacelated at the points of ecchymosis. Trousseau saw diplopia and 
phlebitis of all the superficial veins about the end of the third week. 
Sometimes oedema of the glottis quickly proves fatal to the sufferer, and 
I have treated three cases of this kind in which tracheotomy proved only 
a temporary palliative. Throughout the disease the odor of the breath 
is so extremely fetid that it is alone often sufficient to enable a practi- 
tioner who has once previously seen a case to diagnose the disease as soon 
as he enters the room of the patient. When, however, the gangrene is 
of very slight extent, this symptom may be absent. 

On inspecting the pharynx in the first stage of the disease the appear- 
ances are generally by no means characteristic of the approach of so seri- 
ous an affection, although the peculiar foul smell of the breath may be 
quite perceptible. As soon, however, as the process of gangrene has 
commenced, the back of the pharynx, the pillars of the fauces, and the 
tonsils can be seen covered with discolored patches — sometimes almost 
black, which are slightly elevated above the surrounding surface, and 
forming eschars ultimately detach themselves from the tissues beneath. 
Ulcerations, variable in extent and depth, result from the separation of 
the sloughs. In the worst cases the disease makes constant progress in 
the direction of the mouth, the oesophagus, and the air-passages, and ter- 
minates its onward course only by the death of the patient. 

Typical cases of this disease have been described by Gubler 2 and 
Trousseau; 3 and Rilliet and Barthez 4 have reported some instances as 
occurring in children under five years of age. Some of these followed 
an attack of scarlatina or measles, and do not belong to the diseases now 
under consideration, but others were evidently examples of primitive 
gangrene of the throat. 

Pathology. — As most cases of putrid sore throat prove fatal, oppor- 
tunities of studying the morbid anatomy of the disease occur from time 
to time. In those instances where the gangrene is circumscribed, patches 
of an oval or circular shape, from one-twentieth to half an inch in diame- 
ter, are found on the mucous membrane of the pharynx, and frequently 
on the epiglottis and upper part of the larynx. The surface of these 
patches, after death, is depressed, and their color varies from a dark gray 



1 Loc. cit. p. 518. - Loc. cit. 3 Loc. cit. 

4 Archiv. Generates de Med., N.S. 12, 1841, p. 446 et seq. For other cases see 
Musset : Union Med. , 1860, 2d series, t. vii. p. 436 ; and Bouchut : Gazette des 
Hopitaux, 1858, p. 170. 



32 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

to an absolute black. The edges are perpendicular, and ofMirty yellow 
color, and the mortified structures exhale a gangrenous odor. The pro- 
cess of destruction is generally confined to the mucous membrane and 
submucous tissue. The beds of muscular fibre are iaid bare, but their 
substance is usually intact, though sometimes softened. When the eschar 
has fallen off, the resulting ulcer has occasionally been observed to be 
covered with a delicate false membrane. In the worst examples of the 
disease the sphacelated patches can be noted in the larynx, trachea, lungs, 
oesophagus, and throughout the alimentary tract. 

Diagnosis. — The peculiar gangrenous odor is sufficiently characteristic 
to enable a person who has once smelt it to recognize at once the presence 
of the mortifying process. Diphtheria is the only disease that can be 
confounded with putrid sore throat, but the resemblance is not sufficiently 
great to lead an observant practitioner into error. The grayish black 
patches in the pharynx may exist in both diseases, but in diphtheria they 
are at first whitish and gradually become darker, whereas in true gan- 
grene the diagnostic appearance is present from the first moment that the 
eschars begin to form. In diphtheria the submaxillary and cervical 
glands frequently become much swollen at the outset of the disease, but 
in putrid sore throat these parts in some cases remain altogether un- 
affected, whilst in others the tumefaction is but slight. The fetor of the 
breath in diphtheria is not very perceptible at first, but gradually increases 
as the disease becomes developed. In putrid sore throat the distinctive 
gangrenous odor is present at the onset of the malady, and frequently 
even before inspection can detect any considerable lesion in the pharynx. 

Prognosis. — As putrid sore throat is only a local manifestation of a 
profound blood-poisoning, the prognosis is necessarily extremely grave. 
But few cases of recovery are on record, and in most instances the patient 
has been carried off in a few days. Trousseau, 1 however, saw a case which 
ultimately did well, and the example related by Musset 8 also terminated in 
recovery. I have met with two cases which recovered, and three, already 
referred to, which proved fatal. 

Treatment. — Active measures are imperatively demanded in the treat- 
ment of putrid sore throat. Trousseau and Gubler had recourse to ap- 
plications of strong hydrochloric acid, in order to destroy the diseased 
tissues, but, keeping in view the general nature of the malady, little can 
be expected from topical medication. Sedative and antiseptic gargles 
and sprays are the most suitable local remedies. For this purpose borax, 
myrrh, bromide of potassium, and permanganate of potash may be em- 
ployed. The most important indication, however, is to gain time, and if 
possible support the vital powers until the phenomena of the blood- 
poisoning have passed away. With this view quinine and bark should be 
administered every three or four hours, and stimulants freely given. In 
the case successfully treated by Musset, perchloride of iron — about 30 
grains in the twenty-four hours — was given. Whatever drugs are chosen, 
the diet must be of the most concentrated and nutritious description, and 
strong beef-tea, eggs beaten up with brandy, etc., must be administered 
every hour or two. Nutritive enemata, such as are recommended in the 
article on " Stricture of the (Esophagus," should also be had recourse to, 
when the condition of the throat interferes to any extent with degluti- 
tion. 



Loc. cit. " Loc. cit. 



HERPES OF THE PHARYNX. 33 



HERPES OF THE PHARYNX. 

Latin Eq. — Herpes pharyngis. 

French Eq. — Angine herpetique. Herpes guttural. 

German Eq. — Herpes des Schluudkopfs. Herpetische Angina. 

Italian Eq. — Erpete della faringe. 

Definition. — An eruption of the mucous membrane of the pharynx, 
running an acute course, analogous to that of herpes when appearing on 
the skin. 

Etiology. — Exposure to cold appears to be the principal cause of 
herpes of the pharynx. According to Gubler ' the disease is a kind of 
eruption in the throat, constituting, as it were, the crisis of a fever a fri- 
gore. On this account it is most frequent in cold, damp climates, and at 
those seasons of the year when sudden changes of temperature and incle- 
ment weather prevail. In England it is a rare affection, and all the cases 
I have met with have occurred in the spring or autumn. I have met with 
one case in which the disease attacked a child three years consecutively 
— the left side of the palate and wall of the pharynx being the parts 
affected on each occasion. Women, children, and delicate persons are 
most liable to the malady, owing doubtless to their being more easily 
overcome by cold. Feron 3 thinks that mental emotions have the power 
of determining an attack of herpes of the pharynx; whilst Bertholle 3 
believes the affection to be often associated w r ith some uterine disturb- 
ance, and states that it is most frequently seen in females at the men- 
strual periods. Peter 4 considers that the contact of irritating substances 
with the pharynx, such as hot condiments, and acrid, fetid, or miasmatic 
exhalations are often productive of the disease. Finally, Trousseau 5 has 
shown that herpes of the pharynx prevails to a great extent during epi- 
demics of diphtheria, and that the herpetic eruption may resolve itself 
into diphtheritic patches, leading ultimately even to a fatal termination. 

Symptoms. — Herpes of the pharynx is always ushered in by a pre- 
monitory stage of general malaise, and symptoms of pyrexia. In a period 
varying from a few hours to two or three days the patient experiences a 
sensation of soreness and heat in the throat, which is greatly increased by 
swallowing. In most cases the local malady provokes considerable saliva- 
tion. The disease runs an acute course. After four or five days the 
subjective symptoms diminish greatly in intensity, and at the end of a 
fortnight the parts usually regain their normal condition. 

On inspecting the pharynx at the outset of the disease, a variable 
number of single or grouped whitish, opaline, vesicles can be perceived. 
They usually occupy the soft palate, the pillars of the fauces, and the 
tonsils, and at the apex of each vesicle there is often a dark spot. The 
mucous membrane forming the base of each vesicle or group of vesicles 



1 Memoire sur V Herpes Guttural, &c. Union Medicale, January, 1858. 
- De TAngine Herpetique. These de Paris, 1838, No. 219. 

3 De l'Herpes Guttural, &c. &c. Union Med. t. xxx. 1866. 

4 Diet, des Sc. Med , Paris, 1864, vol. iv. p. 715. 

6 Clin. Med. de l'Hotel-Dieu, Paris, 1865, vol. i. p. 307 et seq. 

n 

O 



34 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

is always inflamed, and presents a red, tumefied appearance. The num- 
ber of vesicles varies greatly in different cases. Sometimes only one or 
two can be seen, whilst in the worst instances they are arranged so closely 
together as to become confluent. As Stevenson Smith ■ remarks, the 
soft palate is occasionally so sprinkled over with minute vesicles, of the 
size of the head of a pin, that it appears as if it had been dusted with 
white pepper. The duration of the vesicles is ephemeral; their existence 
varies from twenty- four to forty-eight hours, but in many cases they ap- 
pear in successive crops. As the local morbid action pursues its course, 
the termination of the vesicular stage may take place in three different 
ways. In the mildest cases the vesicles disappear by reabsorption and 
leave no lesion to mark their former situation. In another variety of the 
disease the vesicles burst and a small circular ulcer results, which appears 
deep, owing to the tumefaction of the mucous membrane. In a day or 
two these ulcers cicatrize, the infiltration of the adjacent tissues is re- 
solved, and the part resumes its normal condition. In the third and 
severest form of the disease ulceration takes place, but the sore, instead 
of healing, becomes covered by a false membrane resembling, both in ap- 
pearance and structure, the exudation of diphtheria. These phenomena 
most commonly occur on the palate, and are rarely seen on the posterior 
wall of the pharynx. "When the vesicles are very numerous the patches 
of exudation may unite at some places, so as to form sheets of false mem- 
brane of limited extent. In three or four days, however, the ulcers heal, 
the exudation becomes softened and detached, and the mucous membrane 
recovers its healthy state. In some cases the larynx or the orifices of the 
Eustachian tubes may be the seat of some of these vesicles. The respira- 
tion and hearing may be temporarily affected, but serious symptoms are 
seldom met with. Simultaneously with the outbreak of herpes in the 
throat, the same eruption may manifest itself in .the mouth or on the lips, 
thus affording a clear indication for the diagnosis of the malady. Cer- 
tain idiosyncrasies have also been observed in patients liable to suffer from 
this affection. Thus Tardieu 2 mentions the case of a young man, in 
whom herpes of the pharynx alternated for several years with a similar 
eruption of the internal surface of the prepuce. Other instances have 
been observed in which herpes of the vulva or a general eruption of the 
malady on the skin coincided with the existence of the pharyngeal affec- 
tion. 3 

Pathology. — The consideration of the pathology of herpes belongs to 
the department of the dermatologist, and it is therefore unnecessary to 
enter here on a question which is fully treated in the text-books on 
skin diseases. Suffice it to say that the malady is believed to depend on 
a defect in the innervation of the part brought about by exposure to cold. 
In addition, Gubler 4 has shown that the morbid action which in herpes 
causes the formation of crusts on the skin, may give rise to the evolution 
of a false membrane when the disease attacks mucous surfaces. 

Diagnosis. — Herpes of the pharynx can only be confounded with 
diphtheria, and it is not possible in all cases to differentiate the two dis- 
eases with certainty. . If the case is seen during the vesicular stage, noth- 
ing can be more easy than the recognition of the malady; but at a later 

1 Edin. Med. Journ., Nov. 1863 : False Diphtheria, etc. 
- Manuel de Pathologie interne, 2d edit. 1857. 

3 Gubler : Loc. cit. Peter : Diet, des Sc. Med. vol. iv. p. 715. 

4 Loc. cit. 



RHEUMATIC SORE THROAT. 35 

period, in severe instances, when the pharynx has become the seat of sev- 
eral patches of false membrane, the most experienced practitioner may be 
deceived as to the nature of the disease. According to Peter 1 the diag- 
nosis of herpes of the pharynx at this stage can only be deduced from the 
existence of one or both of two phenomena — viz., (1) the presence amongst 
the patches of exudation of small ulcers, such as are commonly consecu- 
tive to the rupture of the vesicles, and (2) the appearance of small isolated 
spots of false membrane, the transparency of which indicates their recent 
formation, whilst their size and circular shape leads the observer to sus- 
pect the previous existence of a vesicle. The coincidence of a herpetic 
skin eruption with a doubtful throat affection materially assists the diag- 
nosis, although the occurrence by no means affords conclusive evidence 
as to the nature of the internal malady. In the absence of all the dis- 
tinctive marks mentioned above, it is sometimes impossible to arrive at a 
definite opinion, and under these circumstances the case had better be 
treated as one of diphtheria — an error in that direction being least likely 
to lead to any evil results. 

Prognosis. — Sporadic cases of herpes of the pharynx may be pro- 
nounced to be devoid of all gravity. When, however, the disease mani- 
fests itself during an epidemic of diphtheria, the observations of Trous- 
seau, as to the probability of the milder affection becoming metamor- 
phosed into the more serious malady, must be borne in mind. 

Treatment. — As the onset of the disease is generally accompanied by 
considerable fever, a diaphoretic or febrifuge medicine is often service- 
able. In two cases I found tincture of aconite rapidly relieve the symp- 
toms, and, in the case already referred to, of a child very subject to the 
disease, the internal administration of arsenic always rapidly effected a 
cure. The local pain must be met by the use of emollient and sedative 
gargles, and hot, soothing inhalations, such as the Garg. Boracis, Garg. 
Pot. Brom., Vapor Benzoini, and the Vapor Lupuli, etc. (Throat Hosp. 
Phar.); or by the insufflation of starch and morphia (gr. ^), once or twice 
a day. In the last stage of the malady, when the patches of exudation 
are becoming detached, the fetor of the breath calls for the employment 
of antiseptic gargles, of which permanganate of potash in solution is the 
most effective. 



RHEUMATIC SORE THROAT. 

Latin Eq. — Angina rheumatica. 
French Eq. — Angine rhumatismale. 
Germttn Eq. — Rheumatische angina. 
Italian Eq. — Angina reumatica. 

Definition. — An affection of the throat occurring in persons of rheu- 
matic constitution, characterized by suddenness of attack, severe pain, 
and the local appearances of inflammation. The symptoms are fugacious, 
and frequently give place to some local rheumatic manifestation, such as 
torticollis, lumbago, or subacute articular inflammation. 

Etiology. — The poison of rheumatism is the precise cause of this af- 
fection, but its outbreak is generally due to exposure to cold. Persons 
who have had frequent attacks of simple inflammation of the pharynx or 

1 Loc. cit. p. 716. 



36 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

tonsils are liable to this form of sore throat should they at any time be- 
come the subjects of the rheumatic diathesis. 

Symptoms. — The symptoms of rheumatic sore throat have been so 
well described by Trousseau 1 that I cannot do better than employ his 
words. " An individual," he observes, " subject to rheumatic pains takes 
cold. At the end of a few hours he experiences an extremely acute pain 
in the throat, so that he can scarcely swallow a drop of water, nor even 
his saliva, the deglutition of these small quantities of liquid causing much 
more suffering than that of an alimentary bolus. On examining the 
throat the interior of the pharynx and the veil of the palate present a 
redness more or less pronounced. The uvula invaded by the inflamma- 
tion is oedematous and elongated. All these phenomena are going to 
disappear with great rapidity, because they are fugacious, like most affec- 
tions of a rheumatic nature. The next day the acute pain of this angina 
will have ceased as if by enchantment, at the same time that another 
pain will occupy the neck, producing torticollis; whilst the day after, 
one of the shoulders may be the part attacked. Again, another day, and 
the patient will complain of lumbago. As to the angina, its duration 
may vary from twenty-four to forty-eight hours. It is because they have 
had to deal with these rheumatic sore throats that the physicians to whom I 
have referred have been enabled to boast of having gained the power of 
averting incipient inflammations of the throat. Patients who have had 
several attacks of this kind of sore throat are able at the outset to distin- 
guish the rheumatic affection from a veritable phlegmonous inflammation; 
but the physician cannot differentiate the two maladies in the first mo- 
ments of their appearance." In many rheumatic patients the throat affec- 
tion is an invariable precursor of a general attack of subacute rheumatism. 

Diagnosis. — This affection can seldom be diagnosed at its outset, un- 
less the practitioner has observed similar previous attacks in the same 
person, but, as remarked by Trousseau, the patient himself is often able 
to distinguish, by his sensations, the rheumatic nature of the affection, if 
he has suffered before in the same way. The sudden disappearance of 
the angina, and the development of unmistakable rheumatic symptoms 
in some other part of the body, is of course decisive. 

Prognosis. — The sore throat of rheumatism is the least serious of any 
of the local manifestations of that disease, and the only gravity attached 
to the prognosis depends on the possibility that in the resolution of the 
angina the malady may select for its seat some more vital part. 

Treatment. — The acute pain of the disease is best treated by the use 
of emollient and sedative gargles, whilst at the same time warm poultices, 
or spongio-piline, saturated with tincture of opium, may be applied to 
the neck externally. Constitutionally the specific remedies that are sup- 
posed to neutralize, or cause the elimination of, the rheumatic poison, 
such as bicarbonate of potash, iodide of potassium, salicylic acid, etc., 
should be administered. 

Gouty Sore Throat. 

In connection with rheumatic sore throat it may here be stated that 
there is also a species of angina dependent on gout. 2 I have met with 
several well-marked instances. In one case a gentleman who frequently 

1 Clin. Med. de l'Hotel-Dieu, Paris, 1865, t. 1. p. 332. 

2 See Peterson: Dissert, de Angina Arthritica, Upsal, 1793; also Barthez : Traite 
des Mai. Goutteuses, Paris, 1855, p. 202 et seq. 



TONSILLITIS. 37 

suffered from attacks of angina became subject to gout, and was never 
ao-ain attacked with inflammation of the throat. In another case the pa- 
tient was suffering from acute pharyngitis, when the symptoms suddenly 
disappeared, and an acute attack of gout developed in the great toe of 
the right foot; after three days the gouty inflammation of the toe disap- 
peared, and acute hyperemia of the pharynx supervened. Dr. Prosser 
James 1 calls attention to the rarity of the acute affection, though he 
thinks that the mucous membrane of the throat is prone to chronic inflam- 
mation in those of gouty constitution. The treatment should be con- 
ducted on the principles recommended for rheumatism, with such modi- 
fications as the different diathesis may require. 



TONSILLITIS. 

(Synonyms: Quinsy. Cynanche Tonsillaris.) 

Latin Eq. — Inflammatio tonsillarum. 

French Eq. — Esquinancie. Amygdalite. Angine tonsillaire. 

German Eq. — Angina tonsillaris. Amygdalitis. Entziindung der Mandeln. 

Italian Eq. — Angina tonsillare. Tonsillitide. 

Definition. — Acute inflammation of the tonsils, which may be of su- 
perficial character, or extend deeply into the parenchymatous substance, 
and may terminate in resolution, abscess, or chronic enlargement of the 
glands. 

Etiology. — The causes of tonsillitis may be divided into predisposing 
and exciting. Amongst the former, the greatest prominence must be 
given to age. The disposition to the disease commences soon after 
puberty, and is extremely common between fifteen and twenty, reaching 
its maximum between twenty and twenty-five. The disease is seldom 
seen in children before the fifth year, and is equally rare in adults after 
middle age — scarcely any cases occurring after fifty. 

The following table of 1,000 cases, treated by me at the Hospital for 
Diseases of the Throat, illustrates the influence of a^e: — 

Under 10 years 35 



10 to 15 
15 to 20 
20 to 25 
25 to 30 
30 to 40 
40 to 50 
50 to 60 
GO to 70 



J* - m 

Sf 5i9 

143 

51 

9 

nil. 



This table shows the sudden and remarkably increased proclivity to 
the disease soon after puberty; for whilst from 10 to 15 years of age 
there were only 36 cases, from 15 to 20 there were 184. Again, it illus- 
trates the fact that quinsy is more common between 20 and 30 than at all 
■ages put together. The sudden fall after 25 is also remarkable. It will 
be noticed that young children are very little subject to the disease — an 

1 Sore Throat, Churchill, 1878, p. 120 et se,q. 



38 



DISEASES OF THE PHARYNX, 



immunity which is all the more curious, when it is borne in mind that- 
chronic enlargement of the tonsils takes place in 26.5 percent, of cases in 
the first decennium. In the 1,000 cases tabulated above, 597 were males 
and 403 females. 

Enlargement of the tonsils, congenital or acquired, renders the indi- 
vidual prone to attacks of tonsillitis, and a person who has once been af- 
fected with the disease is very liable to have a second attack if at any time 
he should take cold. This rule holds good to such an extent that in some 
patients the tonsils, after repeated inflammations, seem to constitute a 
veritable locus minimce resiste?itice. Under these circumstances, these 
glands appear to sympathize with every irregularity of the body, and an 
error of diet occasioning a slight dyspepsia, or a derangement of the 
sexual organs in females, may give rise to an attack of tonsillitis. Constitu- 
tional delicacy, especially when dependent on the strumous diathesis, may 
also be mentioned as predisposing to quinsy; whilst the poison of gout and 
rheumatism ' occasionally seem to favor the production of the disease. 

The exciting causes of tonsillitis are almost invariably wet and cold. 
A surface chill, especially about the head and neck, causes hyperemia of 
the internal surface of the throat, and the tonsils are apt to suffer from 
temporary vascular engorgement. In proportion to the susceptibility of 
the individual the accidental hypersemia is likely to lead to an attack of 
quinsy. It is commonly supposed that the disease is most prevalent in 
the spring and autumn in this country, owing to the sudden changes of 
temperature and inclement weather of those seasons. 

This, though true of autumn, is a mistake as regards the spring, as 
the following statistics, taken from cases treated at the Hospital for Dis- 
eases of the Throat, conclusively show: — 





1872. 


1873. 


1874. 


1875. 


1876. 


Total 
No. of 
Cases. 


Mean 

monthly 

of 5 years. 


January 


14 

10 
9 
11 
15 
13 
17 
19 
43 
41 
17 
11 


16 
16 

9 

5 
10 

8 
32 
24 
20 
47 
21 

5 


15 

8 
12 
10 
15 
15 
16 
24 
51 
33 
20 

8 


21 

17 
27 
18 
30 
11 
32 
25 
52 
26 
22 
16 


20 

19 
7 
15 
7 
22 
14 
15 
39 
31 
21 

9 


86 

70 

64 

59 

77 

69 

111 

107 

205 

178 

101 

49 


17.2 


February 


14.0 


March 


12.8 


April 


11.8 


May 


15.4 


June 

Julv 


13.8 
22.2 


August 


21.4 


September 

October 


41.0 
35.6 


November 

December 


20.2 
9.8 








220 


105 


235 


297 


219 


1,176 


19.6 



Mean monthly average 19.fr 

Average monthly mean of the three spring months (March, April, 

May) 13.33 

Average monthly mean of the three autumn months (Sept., Oct., 

Nov.) . 32.26 

1 Desnos: Diet, de Med. et de Chirurg. Prat., Paris, I860, vol. ii. pp. 118, 449 ; 
Pollock : Holmes's System of Surgery, vol. iv. p. 339. 



TONSILLITIS. 39 

There is, however, a possible fallacy in the statistics, which must not 
be overlooked. From the above tables it would appear that quinsy is 
more than twice as common in July as it is in December, but it must be 
borne in mind that persons suffering from acute disease of the throat are 
far more likely to go out to a hospital in July than they are in December 
or even March or April. This probable source of error does not, how- 
ever, apply to the comparisons between spring and autumn, as both seasons 
are about equally inclement in this country. 

Tonsillitis seems to have occurred in an epidemic form in some few in- 
stances, but, from the published accounts, there is great difficulty in dis- 
tinguishing cases of simple tonsillitis from epidemics of scarlet fever. 1 
One instance, however, has been described with such care and precision 
by Mayenc 2 that little doubt can remain as to the almost purely tonsillar 
nature of the malady. This epidemic occurred in 1818 at Gordon, in 
France, and lasted for upward of five months', attacking males and 
females, from fifteen to thirty years of age, in almost equal proportion. 
Inflammation of the tonsils occurs not only as one of the phenomena aris- 
ing from the specific blood-poison of scarlet fever, but it may also be pres- 
ent in connection with variola or measles. Desnos 3 states that prolonged 
residence in a very high temperature, especially if the air be vitiated, may 
produce an attack of quinsy. Tonsillitis may also originate from the in- 
halation of irritating gases or from swallowing caustic substances. In 
such cases, of course, the affection is only a part of a general lesion of the 
respiratory or alimentary tract. Finally, mechanical causes may give rise 
to inflammation of the tonsils. The most common of these are wounds, 
gunshot accidents, 4 the impaction of foreign bodies in the gland during 
deglutition, such as a piece of bone, the fragment of a fruit-stone, etc. — ■ 
and the accretions of cheesy or calcareous matter in the lacuna? of the 
tonsils. 

Symptoms. — The symptoms attendant on inflammation of the tonsils 
vary, both constitutionally and locally, in proportion to the intensity of 
the morbid action in the part, and hence it is useful to make some division 
of the malady with a view to the due application of therapeutics. Vidal b 
separates tonsillitis into erythematous and phlegmonous, i. €., superficial 
and deep, whilst Wagner 6 distinguishes no less than five different forms,, 
viz., (1) simple or superficial, (2) lacunal or follicular, (3) parenchymatous,. 
(4) tonsillitis with abscess in the substance of the gland, and (5) peri- or 
retro-tonsillar abscess. Clinically, however, there is no well-marked line 
of demarcation between the five varieties enumerated by Wagner, and as 
regards treatment it is sufficient to make two divisions of the disease, 
namely: (1) superficial or follicular tonsillitis, and (2) deep or parenchy- 
matous tonsillitis. The inflammation is generally limited to one tonsil. 
The symptoms which usher in an attack of quinsy are those of a general 
malaise, with thirst and heat of skin, and in the severer forms there may 
be a rigor, and occasionally vomiting. These manifestations are accom- 
panied or quickly succeeded by a sense of stiffness and dryness in the 
throat, which leads the patient to make constant efforts at deglutition. 
By degrees the act of swallowing becomes more painful, and as the local 



1 Vidal : Diet, des Sciences Medicales, vol. iv. p. 19 ; also, Desnos : Loc. cit. p. 129. 

2 Bulletin de la Faculte de Med. de Paris, 1819, t. vi. p. 396. 

3 Loc. cit. p. 130. 

4 See a case consequent on a pistol shot, by Bedor : Bull, de l'Acad. de Med., 1833. 

5 Loc. cit. 

6 Ziemssen's Cyclopaedia, vol. vi. p. 911 et seq. 



40 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

inflammation increases the symptomatic fever rises — especially in persons 
who have not previously suffered from the disease — to such an extent 
that in the case of young persons the temperature in the first forty-eight 
hours may reach 105° Fahr. The constitutional phenomena are less 
marked in the follicular form of tonsillitis, and are most severe when the 
inflammation is about to lead to the formation of an abscess. In persons, 
however, who are subject to the malady the fever seldom runs high. In 
those of debilitated constitution the fever occasionally assumes a typhoid 
character, whilst the local affection after a few days subsides into a sub- 
acute form, in which the tonsils are partially covered with an ashy exu- 
dation, or honeycombed with ragged and indolent ulcerations. These 
local phenomena are most apt to occur when the lacunae of the glands are 
blocked up by caseous matter or calcareous formations. In the ordinary 
run of cases, as the disease develops, the tonsil becomes so much swollen 
as nearly to block up the isthmus of the throat, and to fill almost the 
whole pharyngeal cavity, rendering deglutition so extremely painful and 
difficult that the patient is afraid to swallow nutriment even in the liquid 
form. In follicular tonsillitis the swelling of the tonsils is less considera- 
ble, but the mucous membrane is of a very bright red color, and the fol- 
licles exude a white secretion, which slightly adheres to the point of exit, 
and gives the patient who examines his own throat the idea that he has 
several ulcers. In parenchymatous tonsillitis, there is not only great 
congestion and increase in size of the tonsils, but all the adjacent parts 
of the pharynx and palate may be seen to participate in the morbid action. 
A thick mucous secretion and a viscid saliva clog the mouth and throat 
of the sufferer, and respiration may be somewhat impeded. The voice 
acquires a nasal intonation, or is reduced to a mere whisper, the mouth 
can scarcely be opened, the head is moved with difficulty, owing to the 
swelling of the deep tissues of the neck, and the breath is intolerably 
fetid. Under these circumstances it is often difficult, and sometimes im- 
possible, to get a view of the inflamed tonsils. In many cases — especially 
in the follicular form of the affection — after the disease has lasted two or 
three days the pharynx becomes covered with a layer of dirty, yellowish 
mucus, which bears some general resemblance to the false membrane of 
diphtheria, and has sometimes led to an error in diagnosis. The mucous 
secretion, however, which covers the tonsils in quinsy, possesses neither 
texture nor adherency, and can easily be wiped off the surface of the 
glands. 

Velpeau x ,and Beraud have observed instances in which the inflamma- 
tion extended through the cellular tissue of the neck as far down as the 
clavicle; whilst Morgagni 2 and MM. Rilliet and Barthez 3 report cases in 
which tonsillitis terminated fatally by suffocation. In almost all severe 
attacks of quinsy the hearing is affected, and occasionally the extension 
of the disease up the Eustachian tube gives rise to inflammation of the 
middle ear. 4 CEdema of the glottis is also a complication of quinsy, but 
happily a rare one; the inflammation, however, more frequently extends 
to the epiglottis 5 and the base of the tongue. 

Follicular tonsillitis usually undergoes spontaneous resolution" in three 

1 Manuel d'Anat. Chirurg., Paris, 1862. The authors demonstrate the continuity 
of the areolar tissue covering the tonsil with the general areolar tissue of the neck. 

2 De sed. et Caus. Morb. , epist. xliv. 

3 Traite des Mai. des Enfants, 1853, vol. i. p. 227. 

4 Follin : Gazette Hebdomadaire, 1864, p. 155. 
6 Louis: Bulletin de Therap., 1848. 



TONSILLITIS. 41 

or four days, but in parenchymatous inflammation or abscess of the ton- 
sil a healthy condition of the parts is not generally re-established for ten 
davs or a fortnight, and the disease may even be protracted for three 
or four weeks. Slight ulceration of the tonsils nearly always remains 
when the inflammation has caused the extrusion of inspissated cheesy 
matter or calcareous concretions which had previously blocked up the 
lacuna? of the glands. Occasionally a number of small superficial abscesses 
or pustules form on the surface of the tonsils, and these abscesses on dis- 
charging themselves give rise to ulcerations which, in cachectic persons, 
are very obstinate in healing. Gangrene is a very rare termination in 
tonsillitis, but may happen as a consequence of the highest degree of 
parenchymatous inflammation. Cases have been seen by Grisolle, 1 
Trousseau, 8 Frank,' and especially by Borsieri, 4 according to whom the 
phenomena of such an issue are a sudden diminution of pain and dys- 
phagia, the appearance of a bluish patch on the tonsil, and after a day 
or two the expectoration of a putrid, sanious matter, having a peculiar 
odor, which Borsieri thinks pathognomonic of the occurrence. I have 
never met with such a case. When tonsillitis proceeds to suppuration, 
the patient usually complains of lancinating pains in the part, and well- 
marked rigors generally precede the formation of an abscess. It is un- 
usual for both tonsils to become the seat of an abscess, but when such an 
occurrence does take place, suppuration very rarely occurs in both glands 
simultaneously. One gland becomes affected after the other has sup- 
purated, and the inflammation may terminate in abscess. As a rule, the 
pus shows a tendency to evacuate itself at the anterior part of the tonsil, 
and the abscess projects toward the mouth. Occasionally, however, it 
points near the posterior w r all of the pharynx, and under extremely rare 
conditions may make an opening for itself externally at the angle of the 
jaw. If the abscess be not opened by the surgeon and do not burst 
spontaneously, it may occasion so much swelling internally as to interfere 
seriously with respiration. Professor Stoerk 5 has pointed out that fluc- 
tuation may often be detected at a very early period by placing the fin- 
gers of one hand below and behind the ramus of the lower jaw, and press- 
ing the soft tissues inward, whilst the index fing-er of the other hand is 
introduced into the mouth and placed in contact with the inflamed part. 
In some cases the pus has been known to burrow through the cellular 
tissue of the neck as low down as the upper surface of the clavicle. 6 In 
a case reported by Montague, 7 the quantity of matter was so great that 
the patient, a young soldier, was suffocated by the sudden bursting of the 
abscess. At the post-mortem examination the larynx and the upper part 
of the trachea and oesophagus were found filled with pus. Such an acci- 
dent as the foregoing is most to be dreaded should the abscess burst dur- 
ing sleep. A curious case is recorded by Roche, 8 in which the pus from 
a tonsillar abscess passed along the course of the great vessels of the neck 
and penetrated into the chest. Abscess of the tonsil is also dangerous 
on account of the external face of the gland being in close proximity to 

1 Traite de Patholoo-ie Interne, t. i. Art. Amygdalite, 1862. 

2 Clinique Med. de l'Hotel-Dieu, Paris, 1865, 2d ed. t. i. p. 392. 

3 Traite de Medecine Pratique, trad, de Double, 1842, vol. i. p. 114, vol. ii. p. 164. 

4 De Angina, Institutions de Med. Prat., 1798, t. iii. p. 343. 

5 Klinik der Krankheiten des Kehlkopfs, Enke, Stuttgart, 1876, p. 109. 

6 Velpeau : Loc. cit. 

7 Dissert, de Angina Tonsillari, etc., Strasbourg, 1823. 
"Diet, de Med. et de Chirurg., Art. Amygdalite, 1829. 



42 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

the internal carotid artery. After middle life, according to Chassaignac,' 
the artery in this situation describes a curve with the convexity directed 
inward which brings it still closer to the tonsil. Grisolle 2 mentions a 
case in which the abscess gave rise to ulceration of this vessel, and thus 
to serious hemorrhage; whilst Caytan, 3 Midler, 4 Norton/ and others re- 
port similar instances which led to an immediately fatal result. Chronic 
enlargement often remains after the acute inflammation of the glands has 
passed away. 

Paralysis of the pharynx and palate, with or without anaesthesia, some- 
what similar to that which so often follows diphtheria, is also an occa- 
sional consequence of a severe attack of quinsy. 6 It is a rare condition, 
and when present is generally limited to the side of the throat which has 
been the seat of the tonsillitis. Paralysis of the pharynx is indicated by a 
difficulty in articulating those sounds which require the closure of the 
posterior nares, and by slight dysphagia, which is found to persist long 
after all the acute symptoms of the malady have subsided. The difficulty 
exists in making the first effort of deglutition, and can usuallv be over- 
come by a little resolution on the part of the patient. As soon as the 
bolus passes below the superior constrictor, it proceeds downward to the 
stomach without any further difficulty. When the soft palate is alone 
affected, and the rest of the pharynx escapes, the symptoms are less 
marked. There may be, however, slight difficulty in swallowing — espe- 
cially fluids, and nasal intonation of the voice. These palsies are, how- 
ever, such rare sequelae of quinsy that it is scarcely necessary to refer to 
them except as possible results. 

Pathology. — As tonsillitis so rarely proves fatal, few opportunities 
have occurred where the pathologist could demonstrate the precise effects 
of acute inflammation on these glands. When the morbid action is 
superficial the mucous membrane, which covers the tonsils and dips into 
the lacunae, is almost the only structure affected. In cases of parenchy- 
matous inflammation, however, a much more important series of phe- 
nomena may be observed. Thus, in an instance recorded by Didelot, 7 the 
autopsy revealed extensive suppuration in the substance of the right 
tonsil, whilst the uvula was oedematous, and the mucous membrane of 
the palate infiltrated with pus. In addition, the base of the tongue was 
thickened and engorged, the follicles being filled with a concrete sebaceous 
matter, and a section of the organ showing effusion of pus between the 
muscles. In the case of Montague, already referred to, inflammation and 
thickening of the walls of the internal jugular vein and its branches were 
found at the post-mortem examination. Pus and clots were also present 
in the interior of these vessels, which accounted for the engorgement observ- 
ed in the submaxillary and parotid glands and the neighboring lymphatics. 

The tonsils often remain persistently enlarged after an attack of ton- 
sillitis — the result of thickening and induration of the parenchyma of the 
gland. 

1 Leqons sur 1' Hypertrophic des Aroygdales, Paris, 1854, p. 7. 

2 Traite de Pathol. Interne, Paris, 1862, t. i. p. 269. 

3 Prager Vierteljahrsschrift, 1861. 

4 Wurtemberger Med. Corresp. Blatt., 1855. 

5 The Throat and Larynx, London, 1875, p. 12. Mr. Norton's patient was a little 
girl aet. four. 

6 See cases by Maingault : Sur la Paralysie du Voile du Palais a la Suite d'Angine, 
Paris, 1853 ; Gubler : Memoires sur les Paralysies, &c. ; Archiv. de Med., 1860-61. 

7 De TAmygdalite Aigue — These die Paris, 1850, No. 153. 



TONSILLITIS. 43 

Diagnosis. — The diagnosis of tonsillitis presents little difficulty. Nev- 
ertheless mistakes are frequently made, and the high mortality attribu- 
ted to this disease in the annual returns of the Registrar-General, to be 
hereafter referred to, must be due to this cause. I have twice been con- 
sulted in cases of tonsillitis mistaken for laryngitis. In both affections 
there may be pain in swallowing, but when the larynx is the seat of in- 
flammation the voice almost always becomes hoarse or is reduced to a 
mere whisper at an early period of the attack. In the laryngeal disease 
inspection of the pharynx at once shows the absence of any lesion in the 
upper part of the throat, whilst the laryngoscope reveals the actual con- 
dition of the larynx. Some discrimination is required in order to dis- 
tinguish the sore throat of the first stage of scarlet fever from tonsilli- 
tis. Even hydrophobia has been mistaken at its outset for quinsy. The 
whitish follicular secretion, which often veils the tonsils in tonsillitis, has 
caused the affection to be mistaken for diphtheria, and has led to the sup- 
position that the more serious disease has been cured by some simple 
measures. In all cases it is well to suspend the judgment for twenty- 
four hours, after which time the divergence of symptoms in any of the 
maladies which simulate quinsy is so apparent that the careful observer 
can usually arrive at a positive decision. 

Prognosis. — The prognosis as regards life is so seldom unfavorable 
that the rare cases which terminate fatally must be viewed as merely acci- 
dental. 1 It is well, however, to bear in mind the possibility of such 
casualties in order to foresee and obviate them when the symptoms an- 
nounce the advent of grave complications. With respect to complete 
recovery the prognosis in tonsillitis is not always favorable, though it 
usually is so in patients of sound constitution. In debilitated persons 
there is great probability of hypertrophy and chronic inflammation of the 
tonsils remaining after a severe quinsy. A liability to frequent subse- 
quent attacks is also one of the most troublesome after-consequences of 
this disease. 

Treatment. — The superficial forms of tonsillitis generally undergo 
spontaneous resolution in two to five days, and call for little treatment be- 
yond such simple measures as confinement to the house, a light diet, and 
a dose or two of some mild aperient. A rhatany lozenge (Throat Hosp. 
Phar.), taken every three or four hours, will also materially hasten the cure 
of the disease. In cases of deep tonsillitis the treatment required is much 
more active, but fortunately there is a remedy which, if administered at 
the outset of the attack, will almost always cut short the crescent inflam- 
mation. This is guaiacum. Dr. Home, 2 who well remarked, instar spe~ 
cifici in hoc morbo operatur, did not at all overstate the influence of the 
drug. It was formerly much given for this complaint in the form of the 
ammoniated tincture, but fifteen years ago Dr. Crompton, of Manchester, 
recommended me to try it as a powder. Taken in this way it seems to 

1 According to the Registrar-General's Returns, 226 persons died of quinsy in Eng- 
land in 1875, and the number has varied between 110 and 569 every year since 1848, 
except in the year 1 858, when 623 deaths were returned. It is well to bear in mind 
that in that year diphtheria attained great epidemic force, whilst it was still but little 
understood and sometimes altogether unrecognized. The mortality returns gradually 
decreased from that time, and fell as low as 110 in 1872. It is scarcely necessary to 
point out that these returns are the results of errors in diagnosis, and it is a matter of 
regret to find that lately there has been a slight increase in the returns. Thus in 1873 
the reported deaths were 158 ; in 1874, 173; and in 1875, 220 ! 

1 Principia Medicinas, part iii. sec. 4. 



44 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

have a local as well as constitutional effect. Soon after I prescribed it 
as a lozenge, and it is now largely used in that form. A lozenge contain- 
ing three grains of the resin (Throat Hosp. Phar.), given every two hours, 
will seldom fail to arrest the disease at its first onset. Tincture of aconite 
in doses of two to five minims every three hours is sometimes very effica- 
cious. This remedy, for which we are in a great measure indebted to 
homoeopathy, has been strongly recommended by Dr. Ringer, 1 who ad- 
vises that half a drop or a drop of the tincture, in a teaspoonful of water, 
should be given every ten minutes or quarter of an hour for two hours — 
and afterward hourly. According to Dr. Ringer, a high temperature 
both affords the indication for the administration, and assures the suc- 
cess, of this remedy. In my hands this drug, however, has not proved 
so useful as guaiacum. When the disease is not seen at the commence- 
ment, the above remedies will fail to shorten its course, but the constant 
sucking of ice may still sometimes prevent the further development of 
the attack. We must also have recourse to such general therapeutic 
measures as are calculated to guide the morbid action to a favorable 
issue. The bowels should be kept open, the diet should consist entirely 
of nutritious soups r milk, etc., whilst locally, mildly astringent or sedative 
gargles of tannin, borax, opium, etc., may sometimes be used with ad- 
vantage. The immediate sensations of the patient are the best guide as 
to the use of the different kinds of gargles, or, indeed, as to the employ- 
ment of gargles at all. Sometimes they cause great pain, and should not 
then be used. A dose of Dover's powder at bedtime is also very bene- 
ficial when there is much fever and vascular excitement. Some prac- 
titioners have confidence in the direct application of mineral astringents, 
and Velpeau 3 especially recommends powdered alum and nitrate of silver. 
The pigment of chloride of zinc (Throat Hosp. Phar.), brushed over the in- 
flamed tonsils two or three times a day, is sometimes productive of great 
benefit, and even less frequent applications often do good. I quite agree 
with Trousseau, however, that there are certain cases in which the inflam- 
mation inevitably leads to suppuration, and that in these cases all reme- 
dies are powerless to turn it from its path. The morbid action marches 
onward, unchecked in its course, until the formation and discharge of 
pus announces the completion of the process. In these cases of tonsillitis 
icith abscess the best endeavors of the medical attendant should be di- 
rected to encouraging suppuration and shortening the stages of the dis- 
ease. With this view a constant succession of warm poultices should be 
kept applied to the throat, while the patient should make persevering 
use of hot inhalations of steam to which some sedative, such as benzoin, 
hop, or conium (Throat Hosp. Phar.) may be added, and he should also gar- 
gle frequently with warm water. As soon as pus has formed, it is better to 
open the abscess at once than to leave it to evacuate itself spontaneously. 
The incision should be made with the pharyngeal bistoury, the point and 
cutting edge of the knife being directed upward and inward toward the 
median line. In the case of very nervous persons who are afraid of the 
knife, the immediate rupture of the abscess may often be attained by the 
administration of an emetic. Once the matter is evacuated, relief is gen- 
erally almost instantaneous, though convalescence may occasionally be 
retarded in those of feeble organization. On this account it is always 
important to sustain the constitutional powers as far as possible. 

1 A Handbook of Therapeutics, London, 1872, p. 385. 

2 Op. cit. t. 1. p. 453. 



TONSILLITIS. 45 

Formerly the abstraction of blood, either general or local, was the 
primary treatment in all cases. The researches of Louis, 1 however, 
proved how little benefit may be expected from general bleeding. Thus, 
out of twenty-three patients suffering from parenchymatous tonsillitis 
noted by that observer, thirteen underwent venesection and ten were 
treated by other methods. The duration of the disease in the former 
cases was, on an average, nine days, whilst in the latter it was ten and a 
quarter days. This slight abridgment of the course of the malady cannot 
therefore be considered to compensate for such energetic interference. 
With respect 'to local bleeding it has been recommended to apply leeches 
at the angle of the jaw or to scarify the tonsils with the pharyngeal bis- 
toury. If only one or two leeches are applied to each side, the effect ap- 
pears to be the opposite to that desired, and an increased congestion of 
the tonsils often results. The good effect of the local abstraction of 
blood can only be obtained by the application of from three to six leeches 
on either side. A special kind of local bloodletting, i. e., opening of the 
ranine veins, has within the last twenty years been practised to a consid- 
erable extent, and much vaunted in certain parts of France. The princi- 
pal advocates of this measure, which is as old as Hippocrates, are MM. 
Arago 3 and Aran. 3 The latter writer insists on the incision being made 
longitudinally in the veins in order to avoid wounding the ranine arte- 
ries, an accident which, on account of the serious hemorrhage it entails, 
would be likely to bring this kind of bleeding into disrepute. Although 
I have never seen any cases in which such heroic remedies were called 
for, the proceeding certainly appears to have been attended with remark- 
able success in the hands of Aran. 

In cases where the swelling of the tonsils is so great as to threaten 
suffocation, and where it cannot be diminished by the escape of pus, we 
must follow the example of Ancelon, 4 and at once excise the inflamed 
masses. In the middle ages tracheotomy was suggested in such a junc- 
ture, but the operation was not actually performed under these circum- 
stances until the last century. In a recent instance, related by Puech, fr 
of a man ret. 33, who was evidently dying from asphyxia, and on whom 
the attempt to excise the tonsils had failed, recourse was had to trache- 
otomy with the result of saving the life of the patient. Tracheotomy 
was also performed by Mr. Alexander Shaw 6 under similar circumstances. 

Should tonsillitis terminate in gangrene, treatment by antiseptic gar- 
gles will be sufficient until the sphacelated portions of the tonsil become 
detached, when the raw surfaces remaining will usually heal rapidly un- 
der applications of nitrate of silver. 

1 Lancette Franchise, 1833. 

2 Bulletin General de Therapie, &c, 1853. Also Mestivier, Ibid. 1857. 

3 Ibid. 1857. 

4 Gazette des Hopitaux, 1857. 

5 Gazette Hebdomadaire, 1857, p. 592. 

6 Medical Gazette, 1841, p. 190. 



46 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



ENLARGED TONSILS. 

Latin Eq. — Tonsillae intumescentes. 
French Eq. — Hypertrophic des amygdales. 
German Eq. — Hypertrophic der Tonsillen. 
Italian Eq. — Tonsille ipertrofiche. 

Definition. — Chronic inflammation of the tonsils, giving rise to persist- 
ent enlargement and multiplication of the constituent structures of the 
diseased part, and to impairment of the functions of the glands. 

Etiology. — Hypertrophy of the tonsils is sometimes congenital, and 
is often met with in the first months of life. The affections so common 
in infants, such as purulent ophthalmia, eczema and impetigo of the face 
and scalp, nasal discharges, etc., are probably the exciting causes in the 
earliest months of existence. The disease not unfrequently becomes de- 
veloped for the first time about the age of puberty, owing, as some sup- 
pose, to a sympathetic connection between the sexual organs and the 
tonsils. 1 The following table 2 contains an analysis of the ages of 1,000 
patients seen by me at the Hospital for Diseases of the Throat: 

5 to ioi ! ! ; ; 1st | Under 10 > rears 265 

From 10 to 20 years 382 



20 to 30 

30 to 40 

40 to 50 

50 to 60 

60 to 70 



219 
103 

27 
3 
1 



Probably many of the cases in the earliest period were either congeni- 
tal or made their appearance very soon after birth. 

Sex is not without some influence in producing the affection, for out 
of the 1,000 instances recorded in the preceding table, 673 were males and 
327 females. Some cases of hypertrophy of the tonsils result from an at- 
tack of quinsy, but a cachectic state of the constitution, especially if due 
to the strumous diathesis, more often originates the disease. The morbid 
condition of the glands may frequently be observed to date from a severe 
attack of scarlatina, measles, or small-pox with throat complications; and 
Lambron 3 mentions four instances in which the malady was consequent 
on an attack of diphtheria. Syphilis, hereditary or acquired, is also capa- 
ble of producing chronic inflammation of the tonsils, and granular pha- 
rynx 4 is, in some instances, the immediate cause of the malady. Chas- 
saignac 5 mentions a case of nasal polypus which appeared to have had 
some effect in giving rise to tonsillar enlargement. As a rule, hyper- 
trophy of the tonsils, by whatever influence established, tends toward a 

1 Crisp and Headland : Dublin Medical Press, 1849, vol. xx. p. 229 ; and Prosser 
James : Med. Times and Gaz.. Sept. 1859. 

2 See also Chassaignac : Lemons sur l'Hypertrophie des Amygdales, Paris, 1854. 

3 Bulletin de l'Acad. de Med. , 1861 

4 Gueneau de Mussy : Op. cit. ' 5 Op. cit. p. 11. 



ENLARGED TONSILS. 47 

spontaneous cure after the age of thirty, and subsequently to that period 
of life the volume of the glands diminishes so steadily and constantly that 
the decade of from forty to fifty affords few instances of the disease. 

Symptoms. — We can often predicate the existence of enlarged tonsils 
as the child, with its open mouth, drooping eyelids, dull expression, and 
thick voice, enters the consulting-room. On looking into the pharynx 
we can generally at once perceive the hypertrophied tonsils, and in some 
cases they are seen meeting each other in the middle line of the pharynx, 
and entirely concealing from view its posterior wall. The augmentation 
of volume of the tonsils varies in different cases. They are often the size 
of a chestnut, but sometimes attain the dimensions of a bantam's egg, and 
in rare instances they are nearly as large as hens' eggs. The disease 
generally affects both tonsils, but one gland is nearly always more en- 
larged than the other. 

Sometimes the tonsils are only slightly enlarged, but the jagged sur- 
face and dilated lacunae present a honeycombed appearance, and render 
them very prone to inflammation. 

Any considerable degree of enlargement of the tonsils gives rise to 
some difficulty in respiration, and there is generally noisy breathing — 
often snoring — during sleep. As the posterior nares and naso-pharyngeal 
cavity are more or less cut off from the lower part of the pharynx by the 
enlarged glands, respiration through the nose cannot be carried on with 
sufficient freedom, and the patient is consequently obliged to keep his 
mouth constantly open. In swallowing, he sometimes experiences the 
sensation of a foreign body in the throat, and occasionally there is a diffi- 
culty in opening the mouth, owing to the enlarged tonsils interfering with 
the movements of the angle of the jaw. In infants, enlarged tonsils often 
interfere with sucking. 

Attention has already been called to the facial expression of children 
afflicted with enlarged tonsils, but it may be remarked that the peculiari- 
ties of physiognomy are the results of the profound impress which the 
disease exercises on the whole system. The phenomena are mainly due 
to the mechanical effects of the enlarged glands in obstructing respiration. 
The simplest and most common of the mechanical effects of enlarged ton- 
sils is, however, the alteration which the voice undergoes. The cavities 
of the pharynx and nose, which form as it were the sounding-board for 
the vibrations set in motion by the vocal cords, have their functions in 
this respect more or less destroyed, the voice partakes of a nasal intona- 
tion, and the speech becomes thick and guttural. The defect in articu- 
lation is especially noticeable in the case of children between the ages of 
six and twelve in whom the hypertrophy is excessive. 

Interference with the sense of hearing — in some cases amounting to 
almost complete deafness — is a frequent concomitant of hypertrophy of 
the tonsils. It was at one time supposed that compression of the orifice 
of the Eustachian tube played the principal part in the production of 
"throat deafness," ' but the observations of the late Mr. Harvey 3 tend to 
prove that the increase in the size of the tonsil proceeds in the direction 
of the mouth, and that as the tonsil enlarges the Eustachian aperture 
becomes more patent than in the normal state. He therefore attributed 
this form of cophosis to chronic swelling and congestion of the mucous 

1 Chassaignac : Op. cit. p. 37 et seq. 

2 The Ear in Health and Disease, London, 1865, p. 162 ; and The Enlarged Tonsil, 
&c, London, 1850, p. 21 et seq. 



45 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

membrane of the Eustachian tube, and recent l researches have shown 
that one of its chief causes is pressure of Luschka's tonsil on the posterior 
lip of the Eustachian orifice. 

Of all the evil results attendant on hypertrophy of the tonsils, those 
due to interference of the diseased masses with free respiration are the 
most serious. The partial occlusion of the nasal channel posteriorly by 
the enlarged tonsils, obliging the patient to keep the mouth almost con- 
stantly open, renders him unusually exposed to all the external influences 
which produce inflammatory affections of the respiratory tract, whilst the 
persistent obstruction to respiration leads to serious changes in the 
thoracic parietes. In 1828, Dupuytren 2 called attention to the frequency 
with which deformity of the walls of the chest was found associated with 
hypertrophy of the tonsils, without, however, signalling anything besides a 
mere coincidence between the two phenomena. He described the modi- 
fications in the shape of the thorax as consisting in narrowing of the an- 
terior superficies, bulging out of the back, and flattening on both sides, 
but these changes are more characteristic of rachitic disease. Subse- 
quently, this subject was still further investigated by several observers, 
but principally by Mason Warren, 3 Shaw, 4 Robert, 5 and Lambron. 6 
Mr. Shaw called attention to the frequent association of enlarged tonsils 
and the so-called " pigeon-breast," whilst to Lambron is due the credit of 
having most accurately noted the various morbid changes, and of having 
explained their causation in a thoroughly rational manner. According 
to Lambron, the characteristic malformation of the thoracic cavity met 
with in cases of enlarged tonsils, is a circular depression of the walls of 
the chest at about the junction of the lower and middle third. The 
thorax seems as if it had been confined by an unyielding ring which, 
while contracting its growth in this situation, gives an appearance of ab- 
normal bulging to the upper part of the cavity. This circular depression 
corresponds with the attachment of the diaphragm internally to the osse- 
ous framework of the chest, and is evidently due to the constant ener- 
getic contractions of that muscle to overcome the obstacle to free respi- 
ration. In childhood the bones yield easily to such influences, and any 
one who has witnessed the difficulty of breathing which occurs, especially 
during sleep, where there is any considerable hypertrophy of the tonsils, 
will readily understand how pernicious may be its effects on the respira- 
tory apparatus. In addition to the organic alterations in the bones of the 
chest, other evils are brought about, and Chassaignac 7 well observes that 
although increased efforts of the diaphragm, to a certain extent, neutral- 
ize the impediment to respiration, there are frequent intervals when the- 
powers of the muscle become temporarily exhausted, and the oxygenation 
of the blood is very incompletely performed. The vital forces are in con- 
sequence very much lowered, the patient lives in a state of permanent ill- 
health, and easily succumbs to any acute attack of disease, particularly if 
affecting the respiratory organs. 

Besides the various phenomena attendant on hypertrophied tonsils, as 
detailed above, Chassaignac 8 mentions several cases to illustrate the eviL 



1 Michel : Krankheiten der Nasenhohle, &c, Berlin, 1876, p. 102 et seq. 
'Repert. d'Anat. et de Physiol., 1828, t. v. 

3 Philadelphia Medical Examiner. May, 1838. 

4 Medical Gazette, October 29, 1841, p. 187 et seq. 

5 Bulletin General de Therapie Medicale, &c., 1843. 

6 Loc. cit, ' Op. cit. p. 30. 8 Ibid. 



ENLARGED TONSILS. 



49 



effects of the disease on the brain, the digestive organs, and on the senses 
of sight, taste, and smell. He thinks that the local pressure of the en- 
larged glands diminishes the supply of blood to the brain, and impedes 
its return; whilst the digestive organs suffer when there is difficulty of 
swallowing, and also when the diseased tonsils discharge putrid matters 
which find their way into the stomach. With respect to smell and taste, 
I have often observed that these senses are more or less defective in the 
subjects of enlarged tonsils, if the condition has existed for any length of 
time. As regards sight, however, I have not met with any cases in which 
I could trace any clear connection between affections of the eye or modi- 
fications of vision and enlarged tonsils. 

Pathology. — The diseased condition is a true hypertrophy, a veritable 
hyperplasia, in which the volume of the glands is not only increased, but 
increased by a multiplication of all their constituent tissues and follicles. 1 
According to Chassaignac 2 the limit of weight of the enucleated tonsil in 
the cases which he examined was from 
three grammes two centigrammes to 
seven grammes fifty centigrammes. The 
epithelium does not usually show much 
alteration, but the papillae beneath are 
often more numerous and less elevated 
than in the normal state. On making 
a section of an enlarged tonsil, in some 
instances the structures will be found to 
cut with a creaking noise, owing to 
thickening and induration of the con- 
nective tissue, whilst at other times the 
substance of the diseased gland is found 
to be characterized by softness and 
friability. The color of the cut sur- 
face may vary from a dusky red to a 
dirty yellow hue. The lacunae are seen 
to be dilated, and to have their walls 
thickened ; whilst their cavities are 
filled with a viscid mucus, which in some cases becomes consolidated 
into matter of a caseous or even calcareous consistence. Around the 
lacunae are congregated the follicles of the tonsil, which are always 
increased in size and generally in number. The capsule 3 of the tonsil is 
also generally thickened and indurated, and the lymphatic glands of the 
jaw are in many cases considerably enlarged. 4 

Diagnosis. — But little need be said on this point. It is only neces- 
sary to examine the pharynx in order to perceive the increased size, and 
often the diseased surface, of the tonsils. In some cases the tonsils, 
though actually but slightly increased in dimension, seem to have under- 
gone great enlargement, owing to their being rotated forward and in- 
ward toward the median line." In this way they present their internal 
surfaces anteriorly and, stretching across the front of the pharynx, closely 
approach each other. In some persons this movement, which is semi-in- 
voluntary, occurs to a much greater degree than in others, and in such 




Fig. 9.— Section of the healthy tonsil, a, 
hilus ; b, mucous gland ; c, epithelial cover- 
ing ; d, lymphatic follicles ; E, stroma. 



1 Virchow : Krankhaften Geschwiilste, vol. ii. p. 612. 
1 Chassaignac : Op. cit. p. 7. 

4 Griesinger : Archiv. f. Phys. Heilkunde, vol. iv. p. 515. 
6 Chassaignac : Op. cit. p. 8. 

4 



2 Op. cit. p. 13. 



50 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 




cases the peculiarity is at once seen if a disposition to retching is arti- 
ficially produced. If, however, the patient be told to open his mouth and 
inspire deeply, the normal position of the parts will be generally retained. 
At other times the tonsils, although much hypertrophied, are yet almost 
hidden behind the pillars of the fauces. 1 This condition can easily be 
diagnosed by placing the first finger of one hand on the internal surface 
of the tonsil, and that of the other hand externally just behind the angle 
of the jaw, when an accurate estimate of the proportions of the gland can 

at once be arrived at. A little 
familiarity with the usual con- 
formation of the pharynx will 
prevent either of these appear- 
ances leading the observer into 
error. It may be remarked that 
retro - pharyngeal abscess has 
sometimes been mistaken for en- 
largement of the tonsils. 

Prognosis. — Hypertrophy of 
the tonsils occasionally exists in 
the adult — and even in children 
— without giving rise to any in- 
convenience or evil effects. Such 
cases are, however, quite excep- 
tional, and in early life especial- 
ly the disease is one which al- 
most always requires immediate 
attention. The enlarged tonsils 
sometimes spontaneously regain 
their normal dimensions about 
the age of puberty, but by that 
time the morbid condition may 
have seriously impaired the gene- 
ral health of the patient. When 
the hypertrophy takes place in 
adult life, it is seldom productive 
of any evil consequences, except 
in so far as it occasions local in- 
convenience. Should the bodily 
powers, however, be feeble, the 
constitution is likely to suffer, 
and in any case the disease be- 
comes important when, as is often 
the case, the gland is frequently 
attacked bv slio-ht inflammation. 
It is well, however, to remember 
that after the age of thirty a 
progressive diminution in the size of the tonsils, and a gradual ces- 
sation of all the troublesome symptoms, are almost certain to take place. 
Treatment. — The various measures for reducing hypertrophy of the 
tonsils may be conveniently divided into local, constitutional, and opera- 
tive. 

Local treatment consists in the application of remedies to the tonsils 



Fig. 10. — Section of the enlarged tonsil, a, hilus: c, 
epithelial covering ; d, lymphatic follicles : e, stroma ; f. 
increased connective tissue of stroma : g. enlarged vessels ; 
H. slight interruption of the epithelial covering. 

This woodcut is a slightly schematic illustration made 
by Dr. Stephen Mackenzie from sections of a diseased ton- 
sil removed by the author, and shows the appearances 
usually observed on microscopic examination. The lami- 
nated epithelial covering is a good deal thickened. At H, 
the epithelium has given way, probably owing to suppu- 
ration and rupture of some subjacent lymphatic follicles. 
Beneath the epithelium the mucosa is seen to be increased 
by the extra development of lymphatic cells, some of which 
in places insinuate themselves between the epithelial cells. 
The lymphatic follicles are enlarged, and the distinction 
between the follicles and surrounding lymphatic tissue in 
places obscure. No distinct caseation is shown in the 
drawing — none having been present in the case from which 
it was made. The lymphoid cells of the follicles are pack- 
ed closely together, and some of the cells are large and 
pale. In many cases the follicles are much more numer- 
ous than in the illustration, and are arranged in rows per- 
pendicular to the surface. The connective tissue is largely 
increased, and contains much larger vessels than seen in 
the healthy condition. The acinous mucous glands nat- 
urally present in the tonsil have disappeared. 



Guersant : Hypertrophic des Amygdales, Paris, 1864. 



ENLARGED TONSILS. 51 

in order to effect a diminution of their volume. When the enlargement 
is slight, and in a great measure due to irregular thickening of the mu- 
cous membrane covering the tonsils, and to dilatation of the lacunae, pro- 
ducing the honeycombed appearance already described, astringent prepa- 
rations are often productive of decided benefit; but such agents never 
cause any considerable reduction of the gland structure. The most effec- 
tive astringents in such cases are perchloride of iron in solution, and alum 
or tannin in powder. A solution of perchloride of iron ( 3 j. to 3 ij- ad 
| j.) may be painted over the tonsils once or even twice daily with a 
brush. Finely powdered alum or tannin can be effectually applied by 
means of the pharyngeal spatula. The extremity of the spatula should 
be slightly moistened in order that a coating of the powder may adhere 
to it, and the remedy should then be well rubbed into the surface of the 
tonsil. This plan answers better than applying the powder with an in- 
sufflator. The application ought not to be made more than once a day. 
Tincture of iodine painted over the tonsils has often been recommended, 
but has little effect in resolving the hypertrophy. The solid stick of 
lunar caustic has also been loudly vaunted, but it seldom materially less- 
ens the bulk, or improves the pathological condition, of the glands. 
When the glands are really hypertrophied the remedy must be of a de- 
structive character, and escharotics must be used. In my hands the Lon- 
don paste (Throat Hosp. Phar.) has succeeded far beyond any other reme- 
dies of this kind, and has indeed, in many instances, precluded the neces- 
sity for excision of diseased tonsils. Its method of application has already 
been described (page 28). The application may be repeated once or twice 
a week, according to circumstances, on different parts of the surface of 
the tonsil. On each occasion the result is a slough, and a large amount 
of the diseased mass may thus be destroyed in successive layers, until the 
glands have been reduced to a normal volume, or at least to such a size 
as to cease to give rise to troublesome symptoms. It must be confessed, 
however, that the treatment is tedious, and that the guillotine affords a 
quicker method of effecting a complete cure. I have treated a few cases 
successfully by parenchymatous injections of dilute acetic acid (Brit. Phar.) 
with a curved syringe, but the treatment is slightly painful. From ten 
to fifteen injections were used in each case. Dr. Solis Cohen 1 has re- 
duced the enlarged glands by electrolysis — from ten to twenty operations 
having been required in each case. 

Constitutional Treatment. — Whilst any of the measures detailed above 
are being carried out, internal remedies should be administered in order 
to improve the general health, or to combat the morbid diathesis which 
may be present. With this view the diet should be as nutritious as pos- 
sible, and the patient should be treated with special drugs or general 
tonics, such as iodide of potassium, cod-liver oil, and phosphate of iron, 
etc., according to the circumstances of the case. Lambron 2 speaks highly 
of the effects of sulphurous waters (Bagneres-de-Luchon). The patient 
drinks and bathes in the waters, has them applied directly to the pharynx 
and neck by means of a douche used daily for five to fifteen minutes, and 
employs spray inhalations. Dr. Lambron states that the general health 
is always much improved by a course of these mineral waters, whilst in 
very many cases the tonsillar hypertrophy undergoes resolution, and the 
glands are almost reduced to their normal size. 



1 Diseases of the Throat, New York, 1872, p. 132. 2 Op. cit. 



52 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

Operative treatment consists in the removal of a portion of the tonsils 
by abscission. 

Extirpation of the Tonsils. — This operation must have been commonly 
practised at a very early period, for although the first clear mention of it 
is made by Celsus * — a.d. 10 — he speaks of excising the tonsils with 
such familiarity that it was evidently considered a very ordinary and 
trifling procedure. He observes: — "Tonsils which remain indurated 
after inflammation, if covered by a thin membrane, should be loosened by 
working the finger round them, and then torn out; but when this is not 
practicable they should be seized by a hook and excised with a scalpel." 
^-Etius 2 — a.d. 490 — the next writer who gives an account of the operation, 
speaks of it in much more cautious terms. " The portion," he remarks, . 
" which projects — i. e., about one-half of the enlarged gland — may be re- 
moved. Those who extirpate the entire tonsil remove at the same time 
structures which are perfectly healthy, and in this way give rise to serious 
hemorrhage." Paulus ^Egineta 3 — a.d. 750 — instructs us as to excision 
of the tonsils very precisely. He does not approve of operating on them 
when inflamed, and describes them as being most fit for removal when 
they are " white, contracted, and have a narrow base." The head of the 
patient is held, and his tongue pressed down with a spatula by assistants, 
and, the tonsil being seized and drawn outward by a tenaculum, is " cut 
out by the root." Albucasis 4 — a.d. 1120 — evidently takes Paul of ^Egina 
for his preceptor, and gives almost the same directions for performing the 
operation. He is, however, more cautious in his advice, dreads hemor- 
rhage, and fears to excise the tonsils unless when they are " round, whitish, 
and have a narrow base." Subsequently to this period the operation ap- 
pears to have fallen into disuse, and having become almost obsolete and 
traditionary, succeeding writers either omit all mention of it, or approach 
the subject with such timidity as to show that they had had no personal ex- 
perience. Thus even the zealous and indefatigable Ambroise Pare b — 1509 
— counsels tracheotomy when serious enlargement of the tonsils exists, 
and gives a hint also as to ligaturing the hypertrophied glands, but 
makes no remark as to their excision. Fabricius, of Acquapendente 6 — 
1540 — makes some comments on the instructions of Celsus and Paul of 
iEgina, and comes to the following puerile conclusion: — " Whence we 
can perceive that this surgical procedure is neither easy nor altogether 
safe. Wishing that all violence should be avoided in this operation, we 
should, therefore, advise a trial to be first made to loosen the tonsil from 
the surrounding structures with a vectis, and then, having laid hold of it 
with a very slender vulsellum, to pull it outward in order that the gland 
may come away almost of its own accord." Guillemeau/ the pupil of 
Ambroise Pare, advocates a bolder surgical treatment of the tonsils than 
did his master, and does not resort to tracheotomy unless the patient's 
mouth cannot be opened. According to circumstances, he ligatured or 
cut away the diseased masses, and he is opposed to the removal of the 
entire tonsil. In 1637 Severini, 8 during an epidemic at Naples, the 

1 De Medicina, cap. vii. sect. 12. 

BtjSAia 'IarptKo 'E/c/caiSe/ca, Venice, 1534, cap. ii. sect. 36. 

3 New Sydenham Society's Translations, vol. ii. p. 297. 

4 Al-Tasriff. Oxford, 1778, cap. ii. sect. 3G. 

5 CEuvres Completes, Edit. Malgaigne, Paris, 1840, t. i. p. 383. 

6 Opera Chirurgica, Lugduni Batavorum, 1723, col. 4G1-2. 

" Les CEuvres de Chirurgie de Jacques Guillemeau. Paris, 1612, p. 688. 

6 Saint-Germain : Diet, de Med. et de Chirurg. Prat., Paris, 1865, vol. ii. p 156. 



ENLARGED TONSILS. 53 

principal symptom of which consisted in great swelling of the tonsils, re- 
moved large portions of the glands, when sessile, by caustics, and, when 
pediculated, by means of a hook and a kind of a semicircular knife. 
Nevertheless, for a whole century afterward, excision of the tonsils was 
almost entirely discountenanced, although some few surgeons occasionally 
had recourse to the ligature. Dionis ' — 1672 — opposes altogether the 
removal of the tonsils, whether by excision, evulsion, or ligature, and 
states that the glands have a physiological importance which completely 
precludes the advisability of wholly or partially taking them awav. 
Juncker 8 — 1680; Heister" 3 — 1683; and Sharp 4 — 1688— a pupil of Ches- 
elden — all fear to excise the tonsils, and condemn the operation, content- 
ing themselves with feeble attempts to remove portions of the glands by 
ligature or cautery. The opinion of Heister is worth quoting, as his sur- 
gical treatise was, perhaps, the most popular text-book during the first 
half of the last century. " This operation," he observes, " is not only 
too severe and cruel, but also too difficult in the performance, to come into 
the practice of the moderns, because of the obscure situation of the tonsils. 
After 1740, however, the operation by means of the tenaculum and bis- 
toury was again much practised, and the credit of the revival is princi- 
pally due to Meseati 6 and Wiseman. 6 The practice of the latter surgeon 
was first to ligature the tonsil, and then to cut off the projecting portion. 
In 1757 Caque 7 commenced to excise the tonsils at the Hotel-Dieu of 
Rheims, and proved indisputably that the great dread which existed of 
hemorrhage was quite chimerical, and that the resulting wound readily 
healed in a short time. From this date excision of the tonsils became 
one of the recognized operations of surgery, and practitioners began to 
improve the instruments, and invent new methods for performing it. It 
is unnecessary to describe here all the various hooks, forceps, bistouries, 
etc., which were devised during the last century for the excision of the 
tonsils, as almost every eminent surgeon made some modification of the 
instruments used for the purpose by his predecessors or contemporaries. 
The method most generally in favor was, perhaps, that of Louis, 8 who em- 
ployed a blunt-pointed bistoury or pair of scissors, the blade or blades 
being sometimes preferred curved and sometimes straight. The patient 
was placed with his face toward the light, and directed to open his mouth 
widely; an assistant then pressed down the tongue with his finger, or 
with a spatula, whilst the surgeon seized the tonsil with a vulsellum, and, 
drawing it as much as possible toward the median line, cut off the super- 
fluous portion on a level with the pillars of the fauces. After a time the 
scissors gave way to the bistoury, and many surgeons still operate with 
the knife and forceps. 

A description of the tonsillotome or guillotine, and the mode of using 
it, will be found under " Pharyngeal Instruments" (p. 9). 

As regards the respective merits of operation by the tonsillotome, or 
by the bistoury and forceps, it is obvious that the former instrument 

1 Cours d'Optrations de Chirurgie, Paris, 1714, p. 532. 

2 Conspectus Chirurgise tarn Medicae quam Instrumental, Halae, 1721, p. 661. 

3 A General System of Surgery, London, 1768, vol. ii. p. 44. 

4 Surgical Operations, London, 1761, p. 189, 8th edition. 

5 Mem. de FAcad. de Chir. , t. v. Sur la rescission des amygdales tumefiees. 

6 Eight Chirurgical Treatises, London, 1734, vol. ii. p. 30, 6th edition. 
"' Amygdalotomie, 1757. 

8 Mem. de l'Acad. Roy. de Chir., 1774, t. viii. p. 423 : Sur la rescission des Amyg- 
idales. 



54 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

ought to be used in all but exceptional cases. When the tonsils are 
only slightly and irregularly enlarged, or have calculi impacted in their 
substance, the bistoury and forceps may perhaps be more manageable; 
but in all ordinary cases the tonsillotome must be considered to be the 
instrument which modern surgical invention has succeeded in perfecting 
for its purpose. 

In adults the tonsils occasionally attain such a magnitude that they 
cannot be encircled by the ring of the largest tonsillotome. This ex- 
treme hypertrophy generally takes place on one side only, and in such 
cases the wire ecraseur should be employed. This operation, of course, 
occupies more time than when the tonsillotome is used, but is attended 
with little pain, and does not cause any hemorrhage. 

Some practitioners are in the habit of giving large doses of bromide 
of potassium for several days before excising the tonsils. I have made 
an extensive trial of this drug, but cannot state, from my own experience,, 
that I ever saw it produce any marked anaesthesia of the fauces. In ner- 
vous patients, however, especially children, the general action of the 
remedy, as a nervine sedative, may, perhaps, lessen the mental apprehen- 
sion and nervous shock consequent on a surgical operation. With re- 
spect to the use of anaesthetics, such as chloroform, ether, nitrous oxide 
gas, etc., I think that they are wholly uncalled for. The actual operation 
seldom occupies more than ten or fifteen seconds, and in the rare event 
of there being any considerable hemorrhage it is well that the surgeon 
should have the active co-operation of the patient, in order to prevent the 
blood descending into the air-passages. 

As regards hemorrhage following excision of the tonsils I have only 
once met with a case in which the bleeding appeared actually to endanger 
life — and this was before I had discovered the means of arresting tonsil- 
lar hemorrhage, which will be presently described. The experience of 
nearly all writers points to the rarity of any serious hemorrhage, but 
Velpeau 1 has reported four cases in which the internal carotid artery was- 
laid open whilst a portion of the tonsil was being cut away with a bis- 
toury, and a few years ago Mr. McCarthy successfully tied the common 
carotid artery at the London Hospital in the case of a patient suffering* 
from continuous hemorrhage after excision of a tonsil. In the great 
majority of cases the bleeding soon ceases spontaneously, and it is only 
necessary to make the patient gargle and wash the throat with cold water 
for a few minutes. Occasionally a persistent oozing of blood follows the- 
operation, but under these circumstances the tanno-gallic acid gargle of 
the Throat Hospital Pharmacopoeia will at once arrest the hemorrhage. 
Half a teaspoonful of the remedy should be slowly sipped at short inter- 
vals. During the act of deglutition the styptic fluid is worked into the 
cut surface of the tonsil, and the hemorrhage is effectually restrained in 
all cases. In the worst instances the bleeding may recur again and 
again for a day or two, but it can at once be checked on each occasion by 
a prompt use of the tanno-gallic fluid. In most cases sucking ice 2 gen- 
erally stops the hemorrhage. In extreme cases, when the internal carotid 
has been laid open, the common carotid must be ligatured. 

With respect to the method proposed by Celsus, already referred to, of 
tearing out enlarged tonsils by the finger, it is worthy of notice that this 
method has been revived and practised with success by an Italian surgeon 

1 Chassaignac, op. cit. p. 109. 

* Med. Times and Gazette, 18G0, p. 631 



FOREIGN BODIES IN THE TONSILS. 55 

named Borelli. 1 He describes the proceeding as easy of execution, and 
devoid of risk from hemorrhage. " The index finger," he remarks, *' ; is 
placed behind the summit of the gland, and by working from above down- 
ward with the nail, and making traction, the tonsil is detached from its 
bed. The organ can in this way be removed entire with much more ease 
than with the ordinary amygdalotome. A small piece, which does not 
afford a sufficient purchase to the finger in order to be torn away, is gen- 
erally left at the inferior part. It only requires, however, to be seized 
with a forceps, when it can be separated by a slight movement of torsion." 
Finally, as regards the after-treatment of the operation, it may be 
stated that the wound usually heals spontaneously in a week or ten days. 
It is, therefore, only necessary to confine the patient to the house for the 
first few days, and to direct him to avoid all hot, hard, and irritating arti- 
cles of food. Marsh-mallow lozenges (Throat Hosp. Phar.) often give 
great relief by forming a coating over the wounded surface, and thus 
protecting it to some extent from the action of the ingesta. Occasionally 
the wound assumes an unhealthy aspect, and becomes covered with an 
ashy, aphthous exudation — sometimes almost membranous. This condi- 
tion is most frequently seen when the hemorrhage has been more copious 
and persistent than usual. Under these circumstances if the solid nitrate 
of silver be lightly applied daily for two or three days, the cut surface 
will rapidly become a healthy ulcer. In other cases, when there is marked 
constitutional dyscrasia, the wound may be slow in healing, and give rise 
to great pain in swallowing. The discomfort can, however, always be 
relieved in a few days by the application of mineral astringents, such as 
the pigmenta of chloride of zinc or perchloride of iron (Throat Hosp. 
Phar.). In conclusion, the only other evil consequence of the operation 
that can be feared is traumatic inflammation of the pharynx. I have 
never met with a case of this kind, but an instance is mentioned by Lie- 
geois 2 which resulted in oedema of the glottis and death. In the rare 
event of acute inflammation supervening, the practitioner should be 
guided by the rules which govern the treatment of traumatic pharyngitis. 



FOREIGN BODIES IN THE TONSILS. 
(Synonyms: Concretions. Calculi.) 

Latin Eq. — Corpora adventitia in tonsillis. 
French Eq. — Corps etrangers dans les amygdales. 

German Eq. — Fremdkorper in den Tonsillen. 
Italian Eq. — Corpi stranieri nelle tonsille. 

Definition. — Concretions and calculi imbedded in the substance of the 
tonsils — the result of a perverted condition of the natural secretions and 
of closure of the outlets of the lacunae of the glands. 

1 Gazzetta Med. Ital. Pro v. Sard., December 30, 1861. 

* Diet, des Sciences Medicales, Paris, 186(5, vol. iv. p. 31. 

3 Foreign substances, which are arrested and detained by the tonsils, during their 
passage through the pharynx, are considered in the article on Foreign Bodies in the 
Pharynx. 



56 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

Etiology. — When the tonsils are in a state of chronic inflammation, 
the secretions of the follicles are frequently altered in character and aug* 
mented in amount. As a consequence, the lacunae may become blocked 
up by the secretion, which sometimes becomes so inspissated as to attain 
the hardness of a calculus. 1 In some instances calculi have been met 
with as large as a cherry, or even larger. 3 The presence of calculi in the 
tonsils has been thought by some practitioners to proceed from a gouty 
affection of the throat, but this supposition is entirely disproved by the 
analysis of tonsillar calculi, which, instead of being composed of urates, 
consist principally of phosphate and carbonate of lime. 3 

Symptoms. — The symptoms of this disease are not, as a rule, very 
prominent. A slight pricking sensation in the throat is generally com- 
plained of, and when the concretions are large and numerous, there may 
be dysphagia. Occasionally small calculi are discharged spontaneously 
from the tonsil, causing slight soreness and bleeding. In most cases the 
concretions predispose to attacks of quinsy, whilst they not unfrequently 
cause ulceration of the walls of the cavity in which they are contained, 
and sometimes lead to the formation of abscesses in the substance of the 
tonsil. In three instances I have seen prolonged suppuration determined 
by the presence of a calculus, and the purulent discharge only ceased on 
the extraction of the offending substance. 

Pathology . — Several writers have made an analysis of tonsillar accre- 
tions, with a tolerably uniform result as to the composition of these mor- 
bid formations. They vary slightly as to the proportions of their chem- 
ical elements according to the amount of hardness to which they attain. 
Thus they contain phosphate and carbonate of lime, a little iron, soda, 
and potassa, and when soft a considerable amount of water and mucus. 4 
When the lacunar are filled by a gray, semi-fluid, or mortar-like matter, 
microscopic examination reveals the presence of epithelium, cholesterine, 
pus-corpuscles, bacteria, mould-fungi, and molecular masses or globules 
of chalk. 5 

Diagnosis — The presence of concretions or calculi in the tonsils can 
only be recognized with certainty when portions of the foreign substan- 
ces are either discharged spontaneously, or can be seen projecting from 
the lacunae of the glands, or can be felt with the finger or pharyngeal 
sound. 

Treatment. — The only satisfactory procedure consists in the removal 
with forceps of the concretions or calculi ; or, should there be any con- 
siderable hypertrophy of the tonsils, the diseased glands must also be ex- 
tirpated. In such cases the bistoury is sometimes preferable to the ton- 
sillotome, as the blade of the latter instrument cannot always sweep 
round, or cut through the substance of, a large calculus. 



Parasites in the Tonsils. 

As an appendix to this article it may be mentioned that some scat- 
tered instances are on record in which certain parasites, such as hydatids 

1 Louis : Mem. de TAcad. de Chir., t. v. p. 460 et seq. 

2 Wagner : Ziemssen's Cyclopaedia, vol. vi. p. 970. 

3 Desnos : Diet, de Med. et de Chir. Prat., vol. ii. p. 117, Paris, 1865. 

4 Tangier : Anal, d'un Calcul Tonsillaire, Journ. de Chimie Med., 1826. Also Wur- 
zer : Buchner's Rep. f. d. Pharm., xxiii. 2 H. 

5 Wagner : Ziemssen's Cyclopaedia, vol. vi. p. 970. 



DILATATION OF THE PHARYNX. Of 

and trichocephali, have been met with in the tonsils. Dupuytren l relates 
the case of a young woman aged twenty-one, who for eleven months had 
suffered from attacks of inflammation of the tonsils. The left gland was 
considerably swollen, and the surgeon having diagnosed an abscess, 
plunged a bistoury into the tumor. As a result, nearly two ounces of 
watery fluid gushed out, and ultimately a large hydatid cyst, the size of 
a fowl's egg, was extracted. At the time the patient was affected with 
an abdominal tumor,- and as she died soon after from an attack of erysip- 
elas, an autopsy was made. An ovoid cyst was discovered, similar to 
that contained in the tonsil, but as large as a child's head, attached to the 
left kidney. An almost similar case, except that the patient was a man, 
is reported by Davaine, 2 and the same observer relates an instance in 
which a trichocephalus was found lodged in the left tonsil. The parasite 
had probably attained this situation through being expelled from the 
stomach during the act of vomiting. 



DILATATION OF THE PHARYNX. 

(Synonyms: Pharyngocele. Pharyngeal Pouch.) 

Latin Eq. — Dilatatio pharyngis. 
French Eq. — Dilatation du pharynx. 
German Eq. — Erweiterung des Schlundkopfs. 
Italian Eq. — Dilatazione della faringe. 

Definition. — Enlargement of the cavity of the pharynx, either in its 
entire circumference, or at a particular part, so that a pouch or diverticu- 
lum is formed. 

Etiology. — From the nature of its surrounding and supporting struc- 
tures, the pharynx rarely undergoes any considerable concentric dilata- 
tion, except at its lower part, or when the morbid condition also affects 
the oesophagus. 3 Occasionally, in cases of cicatricial contraction or of 
stricture of the gullet, the oesophagus undergoes considerable dilatation, 
and the lower part of the pharynx may participate in this expansion. 
Dilatation of the pharynx, however, is more frequently confined to a lim- 
ited portion of its circumference, and the stretched membrane, by pro- 
jecting in one or other direction, constitutes a pouch or diverticulum. 
Such a protrusion really deserves the name of a hernia, as it consists of 
the mucous and sub-mucous coats only, which pass out between the fibres 
of the muscular tunic of the pharynx. Diverticula of this nature gener- 
ally extend backward and downward, and make their way between the 
cesophagus and vertebral column, whilst occasionally they project later- 
ally and form a tumor at the side of the neck. Rokitansky 4 conceives 
that diverticula sometimes result from small foreign bodies, such as cherry 
stones, having become lodged at some part of the pharynx. The etiology 

1 LeQons Orales, t. ii. p. 179. 

2 Traite des Entozoaires, etc., Paris, 1860. 

3 See a case figured in the article on Dilatation of the (Esophagus. 

4 Pathological Anatomy (Syd. Soc. Trans.), vol. ii. p. 12. 



58 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

of their formation is not clear, but it seems most probable that they 
arise from a weakness at some part of the pharyngeal walls, which causes 
the membrane to yield when any unusual strain is applied. I have met 
with three cases in persons who had resided for many years in tropical 
climates, and in whom there were other symptoms of relaxation. A 
habit of " bolting " food is likely to disturb and vitiate the functions of 
the involuntary muscles of the pharynx and oesophagus, by thrusting 
more substance into the channel than can be carried down without stop- 
page; and I have ascertained that there was carelessness and hurry in 
eating in several of the cases of pharyngeal dilatation that have come 
under my notice. Finally, diverticula of the pharynx have occasionally 
been met with as congenital malformations, and in such cases it is possible 
that they may be relics of the branchial clefts. 1 

Symptoms. — The prominent symptom of a pharyngeal diverticulum is 
dysphagia, i. e., difficulty, unaccompanied with pain, in swallowing. Por- 
tions of food become arrested from time to time in the pouch, which thus 
forms a temporary solid tumor in the neck. In this way, when the di- 
verticulum is situated between the vertebrse and the gullet, the obstruc- 
tion may be so great as to close the passage. In many cases the pheno- 
mena simulate those of stricture of the oesophagus. The diverticulum, 
however, becomes emptied after awhile, and the occurrence is followed by 
a great temporary relief to the patient. Thus the symptoms vary con- 
siderably at different periods. The mechanism by which the contents of 
the pouch are voided is not well understood. The accumulation of food 
is ejected so that the patient thinks he is vomiting, but the process is un- 
accompanied by retching or nausea. In some cases the receptacle dis- 
charges its contents so gradually that a kind of rumination seems to be 
established. In other instances fragments of food find their way into the 
larynx w T hilst passing from the diverticulum, and give rise to severe at- 
tacks of spasm or to fits of coughing.* Such foreign matter may even 
find its way into the lower parts of the air-passages, and give rise to 
bronchitis or pneumonia. Sometimes it happens that the diverticulum 
becomes inflamed, and a cure results from adhesion of the opposite walls- 
of the sac. Such inflammation may, however, lead to sloughing and ex- 
travasation of food into the postpharyngeal connective tissue. Cases of 
pharyngeal pouch may continue for years without causing any dangerous 
symptoms. I have seen several examples where the disease had been 
going on for twenty or thirty years, and was lately consulted by a patient 
in whom the symptoms had existed for fifty-one years. In none of these 
cases was the nutrition seriously affected. In most of them the patients 
had lived for a considerable period on liquid food, and the oldest of my 
patients had supported himself on spoon-diet for twenty-seven years. 

Pathology. — The opportunity for a post-mortem examination rarely 
arises, but in a case reported by Rokitansky, 3 where the s}'mptoms had 
existed forty-six years, the mucous membrane of the back of the mouth 
was thickened, whilst that of the upper part of the larynx was ©edematous. 
On a level with the inferior constrictor of the pharynx the mucous mem- 
brane was prolonged through the fibres of the muscle into a diverticulum 



1 See a case by Mayr in the Jahrbuch z. Kinderheilkunde, iv. 3, p. 209, 1861. 

2 See a preparation in the St. George's Hosp. Museum, Series ix. No. 14. The 
patient, set. 63, died from pneumonia. He had previously suffered from repeated 
attacks of inflammation of the larynx. 

3 Archives Generates de Med., 1840, t. ix. p. 329. 



DILATATION OF THE PHARYNX. 59 

about two inches in length. This pouch was enveloped with the cellular 
tunic of the oesophagus in such a way that the pharyngeal canal opened 
directly into this cavity instead of into the gullet. On trying to pass the 
finger or a sound into the oesophagus it was impossible to avoid diverging 
into the diverticulum. The walls of the pouch contained a few bands of 
pale, muscular fibres, whilst near its aperture the oesophagus was greatly 
narrowed, and the remaining extent of this canal was atrophied. 

Diagnosis. — An uniform dilatation of the pharynx can readily be as- 
certained by digital and laryngoscopic examination. A pharyngocele 
may generally be diagnosed from the history of the case. The difficulty 
of swallowing, the sensation of a foreign body in the throat — augmented 
after meals, the presence of a soft tumor on the outside of the neck, 
which can be dissipated by pressure, and the frequent ejection of small 
portions of undigested food, are all phenomena almost pathognomonic of 
the condition. By the use of a sound the form, size, and direction of the 
diverticulum can usually be determined. 

Prognosis. — Enough has already been said to show that this affection 
is more frequently productive of inconvenience than of any immediate 
danger, although in some cases life is no doubt shortened by the condi- 
tion. The chances of cure are extremely small, and little result can be 
expected from remedial measures, except when the pouch is at the side of 
the pharynx. 

Treatment. — Where there is slight general dilatation, independent of 
stricture of the oesophagus, increase in the contractile power of the con- 
strictors may occasionally be obtained by the frequent application of fara- 
dism and galvanism. In the case of a diverticulum such treatment is un- 
availing, but if the pouch be situated laterally, so that pressure can be 
brought to bear on it from the outside of the neck, the patient is enabled 
to empty it himself, 1 and thus avoid any serious symptoms. In such cases 
swallowing may be greatly facilitated by pressure with the finger on the 
neck opposite the diverticulum whilst eating. Under these circumstances- 
the morbid condition maybe present for an almost unlimited period with- 
out causing anv ill effects bevond an inconvenience during meals. Irk 
several instances I have been able to give great relief to patients by di- 
recting them to wear a stiff stock with a pad over the seat of the diverti- 
culum. When, however, there is danger from repeated suffocative at- 
tacks, or from inanition, it will be necessary to try and avert the peril. 
Should the aperture of the pouch be small, and be visible either by the 
unaided eye or by the laryngoscope, an attempt may be made to produce 
cicatricial contraction of the opening by the local application of galvanic 
cautery. If these measures fail, an operation similar to cesophagotomy 
might be undertaken, and the pouch excised. This having been done, the 
edges of the mucous membrane would have to be carefully brought 
together and secured by stitches. After such a precedure, in order ta 
avoid traction on the wound, it would be necessary to feed the patient 
through a tube until union had taken place. 



1 See Xo. 1886 in the Royal College of Surgeons' Museum, removed from the body 
of a man aet. 90. 



60 DISEASES OF THE PHABYNX, LARYNX, AND TRACHEA. 



CANCER OF THE PHARYNX. 1 

Latin Eq. — Carcinoma pharyngis. 
French Eq. — Cancer du pharynx. 
German Eq. — Krebs des Schlundes. 
Italian Eq. — Cancro della faringe. 

Definition. — Primary malignant disease of the pharynx, generally 
•causing death by starvation, but sometimes by hemorrhage. 

Etiology. — Primary malignant disease of the pharynx may originate 
in the walls of that cavity, or in the tonsils. It is rare in the pharyngo- 
oral space, but very common in the lower portion of the canal, where it 
generally first attacks the posterior wall, and, passing round the sides, 
subsequently invades the larynx. The latter cases are not usually classi- 
fied as pharyngeal affections, but are included in cancer of the oesopha- 
gus; and the remarks commonly made as to the rarity of pharyngeal can- 
cer are based on the observation of the disease by unaided vision. The 
same obscurity which surrounds the etiology of cancer in other parts holds 
good as regards the pharynx, and heredity is the only known influence 
about which there is no uncertainty. 

Out of 8,289 deaths from cancer recorded in the Paris registers 3 were 
ascribed to cancer of the tonsils and 4 to cancer of the pharynx ; a but 
these statistics could only have had reference to cancer in the pharyngo- 
oral cavity. 

Symptoms. — When the disease is in the pharyngo-oral space the tumor 
can always be seen, and can also be felt with the finger. The voice be- 
comes thick, articulation indistinct, and the expectoration fetid. The af- 
fection causes constant pain, which is greatly increased on attempted de- 
glutition. The pain becomes greater when ulceration commences, and 
often darts into the ear. As the disease advances the respiration becomes 
obstructed, and great inconvenience is often experienced from the poste- 
rior nares being blocked up. When the cancer is situated in the pharyn- 
go-laryngeal cavity, the symptoms, course, and termination of the affec- 
tion are almost identical with the phenomena attendant on malignant 
disease of the oesophagus, and the disease generally runs a slower course 
than when it occurs in the pharyngo-oral space. In the lower situation 
there is dysphagia, but often no odynphagia. As a consequence, the 
patient takes more food, and lives longer, and more time is allowed for 
the development of the characteristic cancerous cachexia. The constant 
expectoration of a frothy mucus is a characteristic symptom. The disease 
sometimes leads to perforation of a vessel, from which fatal hemorrhage 
may ensue. 

Pathology. — When the disease is situated in the pharyngo-oral cav- 
ity, it is usually of the scirrhus variety, presenting, as Delpech s remarks, 

1 In this article, the disease is considered in so far as it relates to the pharyngo- 
oral and pharyngo-laryngeal cavities. Cancer of the pharyngo-nasal cavity will be 
considered in connection with diseases of the nose. 

3 Walshe : The Nature and Treatment of Cancer, 1846, pp. 265, 267. 

3 Diet, des Sc. Med., Paris, 1812, vol. iii. p. 611. 



CANCER OF THE PHARYNX. 61 

a considerable resemblance to malignant disease of the rectum. Physi- 
cally the first sign of scirrhus of the upper part of the pharynx is a hard, 
imperfectly circumscribed mass, occupying a variable extent of the sub- 
mucous tissue of the tube, and invested by the mucous membrane, which 
in the early stages retains to all appearance its normal character. At 
this period a hard elevation can usually be felt, whilst pressure does not, 
as a rule, occasion any pain. As the malady progresses the induration 
gradually extends over the greater part of the pharynx, and may involve 
the veil of the palate and the orifices of the posterior nares. Ulceration 
next commences, and extends over the whole of the affected part, pre- 
senting a reddish or greenish white surface covered with fetid exudations, 
and, later, numerous fungous elevations arise from the surface of the ul- 
cer. Tumefaction of the cervical glands about the angle of the jaw gene- 
rally takes place at an early period. I have seen many cases of cancer in 
which the upper part of the pharynx and the epiglottis were both af- 
fected, in which it was impossible to determine in which part the disease 
originated. A case of this sort was exhibited by me at the Pathological 
Societv some years ago, 1 and a typical example has been described and 
figured by Mr. A. T. Norton. 2 

Cancer of the pharyngo-laryngeal cavity is a very common disease. 
It is usually of an epitheliomatous character, though scirrhus occasionally 
occurs. It commonly commences just below the level of the arytenoid 
cartilages. In the earlier stages, pale grayish white slough-like vegeta- 
tions can be seen with the laryngoscope at the lower part of the pharynx, 
surrounded by a zone of bright red, swollen, mucous membrane. Some- 
times the disease commences in the thyroid fossa, but in nearly all cases, 
whether originating at the back or the sides of the pharynx, it extends- 
round the cavity and reaches the air-passage. As the disease progresses,, 
considerable tumefaction of all the tissues takes place, but the cervical 
glands are not generally enlarged. 

Diagnosis. — The diagnosis of cancer of the pharynx seldom presents 
any difficulty, although cases are on record in which syphilitic condylo- 
mata 3 and gummata 4 were mistaken for malignant disease. The use of 
iodide of mercury and iodide of potassium respectively cured the cases 
referred to, and demonstrated the error of diagnosis. A fibroma may also 
be mistaken for encysted cancer, but its peduncle generally serves to dis- 
tinguish it, and it shows no disposition to ulceration. 

Prognosis. — The disease must necessarily end in death, and the only 
doubt which can exist in the prognosis relates to the question as to how 
soon the malady may be expected to prove fatal. The duration of life is 
generally much shorter when both respiration and deglutition are affected 
than when swallowing alone is impaired. 

Treatment. — Palliative measures alone can be adopted. Should res- 
piration be dangerously incommoded, tracheotomy will often obtain a 
prolongation of life, whilst inability to swallow must be met by the use 
of the oesophageal tube, or by the administration of nutritive enemata. 6 
Finally, an attempt may be made to prolong life, by resorting to cesopha- 
gotom y, hereafter described. Scirrhus, in the lower part of the pharynx^ 

! Trans. Path. Soc, vol. xix. p. 71. 

2 Ibid. vol. xvi. p. 53. 

3 Fournier : Plaques muqueuses hypertroph. des Amygdales ; M. Fano : These 
d'Agr» : £ution, IS."")?. 

4 Laucereaux : Treatise on Syphilis (New Syd. Soc.), 1868, vol. i. p. 310. 
6 See the article on Cancer of the (Esophagus, in this work. 



62 DISEASES OF THE PHARYNX, LARYNX. AND TRACHEA. 

is the form of cancer most likely to furnish a suitable case for such an 
operation. 



Cancer of the Tonsils. 

This is a rare disease, but cases have been reported by Velpeau, 1 Mai- 
sonneuve, 2 Lobstein, 3 Lennox Browne, 4 etc. Most of the reported in- 
stances belonged to the encephaloid variety, the disease being in some 
cases primary and in others due to extension from adjacent parts. I 
have met with seven cases of cancer of the tonsils, five of which were 
encephaloid, and two scirrhous. The following short summary shows the 
sex and ages of the patients: — 



Encephaloid. 
Males. Female. 

JEt. 'Z'Z 



37 

58 
67 



JEt. 43 



Scirrhous. 
Male. Female. 



JEt. 47 ... 1 JEt. 34 ... 1 



The average duration of life after the symptoms appeared was seventeen 
months, the maximum having been twenty-five, and the minimum nine 
months. One or both tonsils may be the seat of the malady, which com- 
mences in the form of a tumor situate in the substance of the gland, and 
at a more advanced period presents an ulcer which there is little difficulty 
in recognizing as cancerous. 5 Chronic induration and hypertrophy of the 
tonsils may sometimes simulate malignant disease in the early stages, but 
the history and progress of the case, together with the age of the patient, 
afford a definite clue to the nature of the malady. Hypertrophy of the 
tonsils generally commences early in life, and is rarely met with after the 
fortieth year. Cancer, on the other hand, is seldom met with before the 
adult period, whilst all the symptoms become aggravated with compara- 
tive rapidity, and a fatal termination quickly ensues. When the cancer 
is confined to a portion of one or both tonsils, these organs may be ex- 
cised, with the occasional result of affording the patient a few months' 
respite. 

Cases which clinically are considered cancer, on post-mortem examina- 
tion are often found microscopically to be of the lymphomatous or lympho- 
sarcomatous character. A remarkable instance of this kind has been re- 
ported by Dr. Moxon, 6 in which the left tonsil, the lymphatic glands, and 
the spleen were all the subjects of a brain-like growth. These tumors con- 
sisted for the most part of cells, kept together by a network of fine fibres. 
The cells were larger than lymph-cells, and the interior of each was filled 
with a large nucleus and many nucleoli. I have met with a somewhat 
similar instance in a patient aged fifty-seven, in whom both tonsils and 
the lymphatic glands of both sides were affected with similar cellular 
growths. In this case the development of the tumor was checked for a 



1 Liegeois : Diet, des Sc. Med., Paris, 1864, vol. iv. p. 26. 

- Bulletin de la Societe de Chirurg. : Cancer des Amygdales, 1859. 

3 Anatomie Pathologique, 1829, vol. i. p. 429. 

4 The Throat and its Diseases, London, 1878. 

5 Lebert : Traite des Mai. Cancer., 1851, p. 

6 Trans. Path. Soc, vol. xx. p. 809. 



422. 



NON-MALIGNANT TUMORS OF THE PHARYNX. 63 

long time by subcutaneous injections of acetic acid. I have also seen two 
cases of simple lymphoma of one tonsil, in patients aged respectively 
twenty-seven and thirty-two. In each case life was prolonged by re- 
peated removals of diseased structure, but the affection ultimately proved 
fatal from dysphagia and consequent marasmus. In my three cases of 
iymphomatous disease of the tonsils the patients were men. 



NON-MALIGNANT TUMORS OF THE PHARYNX. 

Latin Eq. — Tumores non maligni pharyngis. 

French Eq. — Tumeurs non malignes du pharynx. Tumeurs benignes du 

pharynx. 
German Eq. — Gutartige Geschwulste des Schlundes. 
Italian Eq. — Tumori non maligni della faringe. 

Various formations of a non-malignant nature are occasionally met 
with in the pharynx. I have treated many cases of papilloma, varying in 
•size from a pea to a small grape, situated on the pillars of the fauces, ton- 
sils, or posterior wall of the pharynx. Luschka, 1 Sommerbrodt, 2 and 
others have also reported cases of pharyngeal papilloma. Large growths 
of fibrous structure and fatty tumors have also been met with in this 
region. Barnard Holt 3 has recorded a case in which a fatty tumor 
springing from the left side of the epiglottis and pharynx hung down into 
the oesophagus for nine inches. The patient was eighty years of age, and 
was nearly suffocated on one occasion by the mass being propelled up- 
ward, and occluding- the larvnx during the act of vomiting. The growth 
was not removed during life, and the man subsequently died suddenly 
while smoking. Two preparations of pedunculated tumors removed from 
the pharynx during life are contained in the Royal College of Surgeons' 
Museum. 4 The first of these is a lobulated mass, about two inches long 
and half an inch in diameter, and resembles a mucus polypus of the nose. 
It was attached by a very slender pedicle, not thicker than ordinary twine, 
just behind the tonsil. In the other case the diameter of the growth is 
considerably greater. The tumor is of irregular spherical shape, and ap- 
pears to be of a fibroid nature. Its surface is covered by mucous mem- 
brane, but is ulcerated at several points. The mode of attachment is not 
quite clear, but the tumor seems to have been attached by a stout, strong 
pedicle to the wall of the pharynx. Voltolini 5 reports the case of a small 
fibroid growth, about half the size of a pigeon's agg, springing from the 
posterior wall of the pharynx, whilst Fischer 6 describes a tumor, appa- 
rently sarcomatous, which extended from the base of the skull to the cri- 
coid cartilage. According to Busch 7 such tumors may take their origin 
from the mucous membrane, from the connective tissue posterior to it, 
from lymphatic glands, or from the periosteum covering the vertebral 
column. Finally, it may be remarked that growths originating in the 

1 Virchow's Archiv, vol. 1. p. 161. 2 Ibid. vol. li. p. 136. 
3 Trans. Path. Soc, vol. v. p. 123. 4 Nos. 1090 and 1091. 

* Galvanokaustik, p. 226. ■ Wiener Mediz. Wochenschrift, 1865, No. 61. 

1 Berliner Charite-Annalen, 1857, vol. viii. p. 1. 



64 DISEASES OF THE PHARYNX, LAKYNX, AND TRACHEA. 

nasopharyngeal cavity or posterior nares often descend into the pharynx 
proper. 

Symptoms, etc. — The main symptoms produced by pharyngeal growths 
are those due to interference by the morbid mass with deglutition or res- 
piration, and they vary with the size and position of the tumor. Small 
excrescences on the fauces or tonsils cause little inconvenience beyond 
an occasional sensation of a lump in the throat in swallowing. In some 
cases the tumor may give rise to troublesome cough, if lying in contact 
with the larynx or epiglottis. The diagnosis of growths in the pharynx 
can generally be made without difficulty on examination with the unaided 
eye or by the aid of the laryngeal mirror. 

Treatment. — Small growths, such as papilloraata, may be torn off by 
strong forceps, or can be quickly destroyed by the application of London 
paste (Throat Hosp. Phar.). Larger formations, if pedunculated, may 
be removed by forceps, by galvanic cautery, or by the ecraseur, or the- 
base may be encircled by a ligature, and the tumor then be cut off with 
the knife. In the case of growths of such a size as to fill up a great part 
of the pharynx, care must be exercised in their removal. Thus we see- 
that in Holt's case the mere displacement of the tumor upward was suffi- 
cient to produce suffocation by occluding the larynx. Should the attach- 
ment of the growth be extensive and vascular, excision is attended with 
the risk of asphyxia from hemorrhage. Under these circumstances it 
has been recommended first to perform tracheotomy, and as soon as the 
patient is able to breathe freely through the tube to remove the morbid 
mass in the pharynx. 1 



SYPHILIS OF THE PHARYNX. 

Latin Eq. — Syphilis pharyngis. 
French Eq. — Angine syphilitique. 
German Eq. — Syphilis des Schlundkopfs. 
Italian Eq. — Angina sifilitica. 

Definition. — Syphilis attacking the pharynx and presenting the phe- 
nomena met with in the three stages of that disease when affecting mu- 
cous surfaces. 

Etiology. — Syphilis of the pharynx may be the result of direct inocu- 
lation with the specific virus of the disease, but is generally a local man- 
ifestation of the malady after it has become constitutional; occasionally 
it is hereditary. The primary chancre, when situated in the pharynx, is 
almost always found on one of the tonsils, owing, no doubt, as Desnos 2 
remarks, to the structure of these glands, the lacunae of which are likely 
to receive and retain the syphilitic virus when introduced into the throat. 3 

1 Durham : Holmes' System of Surgery, vol. iv. p. 489. 

2 Diet, de Med. et de Chirurg. Prat., vol. ii. p. 149. 

3 The revolting practices which lead to these affections have been alluded to by 
Diday and Desnos, to whose writings those interested in the question are referred for 
further information. 



SYPHILIS OF THE PHARYNX. 65 

Diday ! explains that the disease should theoretically be more common 
among females, and my own experience tends to confirm his hypothesis. 
Thus, out of seven cases of primary syphilitic sores which I have met 
with on the tonsils, six of the patients were women. In Diday's own 
cases, however, the affection was divided equally between the two sexes; 
whilst Desnos, 2 from the examination of a mass of statistics, concludes 
that the primary sore is not more frequent amongst females, and explains 
the mode in which the disease is established in this situation in males. 
The rarity of chancre of the pharynx may be estimated from the fact that 
of G73 examples of chancres in all situations, not one was found behind 
the anterior pillars of the fauces; whilst of seventy-seven primary sores 
of the buccal region only one had its seat on the tonsil. 8 Secondary and 
tertiary syphilitic phenomena in the pharynx are among the commonest 
local manifestations of the disease, when it has become constitutional, as 
the result of inoculation or heredity. As Swediaur * observed long ago: 
"When the syphilitic virus is absorbed into the mass of the blood, in the 
majority of cases it produces its first effects on the throat." According 
to Martelliere, 6 the causes which commonly give rise to the ordinary 
acute and chronic diseases of the pharynx determine the specific disease 
to attack that part in syphilitic persons. With respect to the frequency 
with which the throat becomes the seat of lesion in constitutional syphi- 
lis, the same authority states that, on examining seventy-two patients 
affected with the malady, he found only twenty-one in whom the pharnyx 
did not present some characteristic alteration. 6 

Symptoms. — The symptoms of syphilis of the pharynx vary, subject- 
ively and objectively, according to the phase of the disease under which 
they appear. In primary syphilis but one local lesion can occur, viz., the 
product of direct inoculation — the chancre. In the secondary stage, the 
disease may present itself under the form of erythema or mucous tuber- 
cles (condylomata). At the third period, likewise, we may find two dis- 
tinct sets of phenomena in different cases, viz., ulceration and gummata. 
The sequel of ulceration is often contraction of the tissues of the pharynx, 
and narrowing of its canal and the passages leading from it. 

1. Although the primary syphilitic sore is rare, Diday 7 states that he 
has met with eight cases, and believes that the chancre, when occurring 
in this situation, is generally overlooked both by patient and practitioner. 
I have myself seen seven cases in which no reasonable doubt could be 
entertained as to the nature of the disease; but in two of these the diag- 
nosis would have been very difficult from the physical condition alone. 
The local appearance is generally that of an ulcer superficial, but sur- 
rounded by an elevation of slightly oedematous mucous membrane. By 
the touch it can be ascertained to have an indurated base, and in most 
cases there is very manifest swelling of the glands about the angle of the 
jaw. The characters of the hard chancre are not, however, always so 
well marked. Thus, in a patient of Diday's 8 a mere superficial erosion 
of the left tonsil, with slight glandular engorgement, was soon followed 
by the phenomena of secondary syphilis. In two other examples given 
by the same writer 9 a phagedenic form was assumed by the chancres, 

1 Compt. Rendus de la Soc. de Med. de Lyon. 1801-63, t. i. p. 45. 

2 Loc. cit. 3 Ibid. 

4 Pharyngitis Syphilitica, 1801, t. ii. p. 147. 

5 De l'Angine Syphilitique, These de Paris, 1854, No. 6, p. 10. 

6 Ibid. p. 9. 

* Loc. cit. 8 Ib ;j. 9 Ibij. 



66 DISEASES OF THE PHARYNX, LAR1NX, AND TRACHEA. 

and deep, unhealthy-looking ulcers extended rapidly for several days. 
It is only in these cases that local or constitutional symptoms, such as 
pain, stiffness of the jaw, and pyrexia, are likely to attract the notice of 
the patient. As a rule, the chancre runs its course and heals without 
making much impression on the health or sensations of the person af- 
fected. 

2. (a.) Erythema of the pharynx is a very common secondary mani- 
festation of syphilis. Thus, out of 114 women affected constitutionally, 
Pillon } noted the affection sixty-five times. 

The first symptoms of the affection are those of an ordinary sore 
throat, viz., dryness of the fauces, slight pain on deglutition, and occa- 
sionally a mild pyrexia. On inspecting the throat at an early period, the 
veil of the palate, the pillars of the fauces, and the tonsils are seen to be 
uniformly red. In a day or two, however, the erythema shows a decided 
tendency to limit itself by abrupt and well-defined margins to a certain 
portion of the pharynx, and to assume a symmetrical arrangement. Jt 
may affect the fauces on each side and the back of the pharynx — termi- 
nating suddenly at the anterior pillars, or it may cease at the centre of 
one tonsil, whilst extending over the whole of the opposite side. The 
redness never fades away gradually into the healthy tissues, but is 
bounded by a very distinct line of demarcation. According to Pillon, 2 a 
species of erythema manifests itself in the throat at a later period of sec- 
ondary syphilis, which is characterized by a grayish tinge, and by granu- 
lations on the surface of the mucous membrane. 

(b.) Mucous patches (syn. : mucous tubercles, broad condylomata, 
plaques muqueuses) are present in the pharynx in a large proportion of 
cases of secondary syphilis. When occurring as the result of heredity, they 
are found in the upper part of the pharynx and on the fauces soon after 
birth. In adults they are generally seen on the pillars of the fauces and the 
veil of the palate. At first they are very slightly elevated, are of a circular 
or elliptic form, and nearly always symmetrically situated on each side of 
the throat. At a later stage they become the seat of shallow ulcera- 
tions, their surface changes to a grayish white color, and their edges be- 
come uneven. In six or eight weeks they generally disappear spontane- 
ously, their former position being marked by a slightly deeper shade of 
the mucous membrane. While they last they cause considerable soreness 
of the throat, especially on deglutition. The skin manifestations asso- 
ciated with condylomata are usually of the nature of syphilitic papulae, 
though some of the other early syphilides may be present. 

3. (a.) The ulcerations of tertiary syphilis may be divided into two 
varieties, viz., superficial and perforating.* The superficial ulcers most 
frequently occupy the veil of the palate, but they are sometimes seen on 
the pillars of the fauces and the tonsils. They extend with great rapidity, 
but generally attack only the superficial tissues. These ulcers are some- 
times of serpiginous form, and are generally covered with an ichorous 
pus; but if this is cleared away the base is seen to be pale and smooth, 
with here and there some fungous granulations. The edges are irregular 
and jagged, and cracks or fissures sometimes proceed from them and ex- 
tend for a considerable extent into the surrounding tissues. When these 
ulcers occur in scrofulous persons they are often very intractable, and the 

1 Des Exanthemes Syphilitiques, These de Paris, 1857, p. 19. 

2 Loc. cit. p. 13. 

3 See Lancereaux : Treatise on Syphilis (New Syd. Soc.), 1868, vol. i. p. 305. 



SYPHILIS OF THE PHARYNX. 67 

affection has been called scrofido-syphilitic, but there does not seem any 
adequate reason for recognizing this complication as a separate disease. 
Perforating ulcers probably always originate in the softening of gum- 
mata. They may be situated on any part of the palate, tonsils, fauces, 
or back of the pharynx, and, as Lancereaux ' says, " they gain in depth 
what thev lose in extent." Commencing by an inflammatory redness, 
after a few days a spot of a dirty white color appears at the centre of the 
inflamed patch, and at this point the tissues beneath become liquefied. 
The destructive action extends deeply, and attacks cartilage, periosteum, 
and even bone. Thus the palate bone, the basilar process, and the bodies 
of the vertebrae may become necrosed or carious. In a case 2 under my 
own care, where there was a deep ulcer on the posterior wall and right 
side of the pharynx, the patient lost more than a quart of blood, and, as 
she soon afterward expectorated the transverse process of the second 
cervical vertebra, the hemorrhage was believed to come from the verte- 
bral artery. Lesions of the brain and spinal cord may also result from 
the ravages of syphilis on the osseous walls enclosing these nervous 
centres. If the skin is affected in this stage of the malady, it is generally 
rupia that occurs. The constitutional symptoms which accompany ter- 
tiary syphilis often denote a serious dyscrasia, and loss of appetite, 
emaciation, and hectic sometimes carry off the patient. Tertiary syphil- 
itic ulceration, destroying the back of the palate, is not unfrequently the 
result of heredity. The ulceration breaks out fresh from time to time, 
and the patients, when brought for medical treatment, vary in age from 
three or four years to fifteen or sixteen. In later years it is not always 
possible to distinguish between hereditary and acquired disease. When 
the disease attacks the pharynx in this way, the anterior part of the 
mouth escapes, and the permanent central incisors are not notched. 

(b.) Gummy tumors, of various parts of the body are amongst the 
most characteristic phenomena of the advanced stage of constitutional 
syphilis. In the pharynx they are generally situated under the mucous 
membrane of the posterior wall, but are sometimes seen in the soft palate. 3 
At first they are small and insensible, and they usually make very slow 
progress. As they increase the mucous membrane covering them be- 
comes injected, and presents a violet-red color. At the same time, the 
glands about the angle of the jaw commence to enlarge. After existing 
for a variable time the gumma arrives at a stage of softening, and per- 
forates the mucous membrane. It may either give rise to inflammatory 
tumefaction of the superjacent tissues, and cause a common form of ter- 
tiary ulceration, leaving no trace of the nature of its origin, or it may 
perforate the mucous membrane at several spots, and give slow exit to a 
continuous discharge of ichorous pus. When the gumma is situated in 
the soft palate the tissues on both sides are eaten through. Thus a fistu- 
lous communication is established between the mouth and the posterior 
part of the nasal cavity. The edges of such fistulas or ulcers are gener- 
ally cleanly cut, and cicatrization proceeds very slowly. In these cases) 
there is generally a disagreeable nasal voice, and in swallowing, fluids 
often pass up into the nose. When gummata are seated at the back of 
the pharynx, they sometimes originate in the periosteum of the vertebral 
column, and, after becoming enlarged and softened, perforate the mucous 
membrane. 4 The termination, however, of gummy tumors is not inevita- 

1 Op. cit. p. 305. ' 2 Trans. Path. Soc. vol. xx. p. 283. 

3 See a case by Martelliere : Op. cit. p. 58. 4 Martelliere : Op. cit. 



68 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

bly ulceration, for they are often reabsorbed under the influence of speci- 
fic treatment. 

When the ulcerative process attacks both the posterior wall of the 
pharynx and the soft palate, the two surfaces may be brought into appo- 
sition by the inflammatory tumefaction, and union of the opposing ulcer- 
ated surfaces sometimes takes place. Dr. Schech ' believes" that cicatri- 
cial contraction of the pharynx is not only the result of deep and exten- 
sive ulceration, but that it is frequently due to superficial erosions and 
denudation of the epithelium. According to that observer, it is not ne- 
cessary that the ulcers or erosions should occur at the same time on the 
pharynx and palate, although, as a matter of fact, they are more often 
simultaneously present. Schech considers that the perforation of the 
palate greatly favors the pharyngeal stenosis. The loss of tissue and the 
consequent altered muscular relations cause a diminution of the normal 
tension of the soft palate, so that its mobility is impaired, and it cannot 
recede from the pharyngeal wall as easily as in health. The base of the 
uvula thus often remains in contact with the wall of the pharynx for a 
considerable length of time — especially when the patient is recumbent. 
Schech further points out that the exit of air through the perforation 
favors adhesion by lessening and diverting the current of air which, in 
coughing, sneezing, and hawking, tends to break down the recently- 
formed adhesions in those cases where there is no opening in the 
palate. 

The isthmus of the fauces loses its normal arch, and the velum, or 
whatever may remain of it, is drawn backward by white cicatricial tissue 
radiating from the hard palate to the posterior wall of the pharynx. 
Sometimes the communication between the nose and the pharyngeal 
cavity is entirely cut off, whilst only a minute opening leads to the lower 
part of the pharynx. When the posterior nasal passage is completely 
occluded, the sensation in the nose is often most distressing. There is a 
constant feeling of dryness and stuffiness, the patient is unable to clear 
his throat, and suffers from loss of smell and taste. When the passage 
to the lower part of the pharynx is contracted, there is difficulty of 
swallowing and dyspnoea. It not unfrequently happens that the entrance 
of the larynx or orifice of the oesophagus is greatly contracted, and then 
the symptoms are even more severe. 

Prognosis. — The prognosis is in most cases favorable as regards life 
in the early syphilitic affections of the pharynx, but serious in relation to 
the later manifestations. Secondary phenomena often pass away with- 
out treatment, and are not dangerous while they last. Should erythema 
extend to the larynx, it does not give rise to oedema of the glottis, nor to 
any serious swelling of the lining membrane. The same remark applies 
to mucous tubercles. The lesions of tertiary syphilis, however, must be 
attentively considered in each case before arriving at a decided prognosis. 
Death may result from the destructive ulceration of the coats of a large 
vessel; and in less serious cases, cicatricial narrowing of the air-passages, 
or destruction or perforation of the soft palate, may occasion permanent 
injury to the functions of the degluto-respiratory canals. Extensive 
ulcerations may lead to caries of the neighboring bones, and induce death 
by establishing a persistent drain on the constitution. Should the base 
of the skull or vertebral column become diseased, fatal lesions of the 
brain or medulla spinalis may, as already remarked, be provoked. The 



1 Deutsches Archiv fur Klin. Medicin., 1870, xvii. Nos. 2 and 3. 



SYPHILIS OF THE PHARYNX. 69 

disease may reach the larynx, and give rise to the dangers hereafter de- 
scribed under " Syphilis of the Larynx." 

Diagnosis. — The diagnosis of a primary syphilitic sore situated in the 
pharynx is beset with uncertainties. Not only is it a difficult and delicate 
matter to ascertain the history of such cases, but the local appearances 
are by no means pathognomonic. On this account it is generally impossi- 
ble to arrive at a decided opinion until the development of constitutional 
phenomena, and the results of treatment combine to confirm our first 
suspicions. If a suspicious ulcer remain obstinate to all internal reme- 
dies and local applications (such as nitrate of silver and nitrate of mer- 
cury, etc.) for four or five weeks, we may feel almost certain as to the 
specific origin of the disease. If secondary syphilitic symptoms subse- 
quently arise, still less doubt can be entertained respecting the nature of 
the primary ulceration. The diagnosis of syphilitic erythema of the 
pharynx depends principally on the simultaneous appearance of the same 
eruption of the skin, and on its symmetrical disposition. The pale, raised, 
symmetrically situated tubercles, surrounded by the brightly congested 
mucous membrane, can scarcely be confounded with any other condition. 
When these guides are not present, the history of the case, and the 
presence of the cicatrix of the primitive sore must be ascertained in order 
to arrive at a definite opinion. Tertiary ulceration is sometimes with 
difficulty distinguished from cancer; but in the latter disease there is 
generally more thickening and less destruction of tissue, and the local 
coloring is much brighter. An ulcerating gumma may resemble cancer 
for a time, but the progress of the case soon reveals its real nature. In 
pharyngeal phthisis the ulcers are generally very small, the dysphagia is 
much greater, and there is generally a very high evening temperature, 
which is altogether absent in syphilis. 

Treatment. — Should a chancre of the tonsil be positively diagnosed, 
the surgeon will either adopt, or abstain from, mercurial treatment, ac- 
cording to his views with regard to the action of that drug. Emollient 
gargles give relief, but should the primary sore present a phagedenic 
character, recourse must be had to cauterization with the acid nitrate of 
mercury. 

Secondary syphilitic affections of the pharynx do not usually require 
any constitutional remedies. For the last eighteen years I have seldom 
employed any specific treatment for adults. Under the use of local reme- 
dies the symptoms rapidly disappear, and I have rarely met with tertiary 
phenomena in the throat amongst those whom I previously treated for the 
earlier manifestations. Hence it is probable that the non-use of mercury 
does not increase the risk of a further development of the disease. 
Should the early phenomena of constitutional syphilis, however, prove in- 
tractable, mercury may be administered. Under these circumstances, I 
generally give it in the form of cyanide of mercury. 1 When the early 
phases of syphilis are seen in newly-born children, mercury, however, acts 
most beneficially — especially in the form of gray powder. The resolution 
of erythema may be hastened by painting the part with a solution of 
chloride of zinc (20 grs. ad § j.), and mucous patches are best treated by 
local applications of tincture of iodine. 

In the tertiary stage of syphilis our chief resource is the internal ad- 
ministration of iodide of potassium. Under the specific influence of this 



1 Form. R. Hydrarg. Cyanid. gr. -fa ; Lactis Sacch. gr. £ . Mucilag. Acacias q.s. M. 
Ft. pil. One pill twice daily. (Throat Hosp. Phar.) 



70 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

drug foul ulcerations become clean and healthy, whilst local tumefactions 
and gummata are resolved and reabsorbed. It is best to begin with five 
grains three times a day. The effect should be watched, and the dose 
may soon be increased with advantage to ten grains three times in the 
twenty -four hours. Thirty grains a day is generally sufficient, but in 
some cases as much as ninety grains may be given daily with advantage. 
In most cases it is advisable to continue the iodide of potassium for some 
time after all local phenomena have disappeared, whilst on the slightest 
sign of any new manifestation the drug should at once be resumed. In 
those cases where iodide of potassium appears to produce only a tempo- 
rary effect, and where recurrences are frequent, recourse may be had to 
the administration of small doses of cyanide of mercury. I have, how- 
ever, seldom found mercury successful where iodide of potassium has 
failed. Locally, the treatment of tertiary syphilitic lesions of the pharynx 
varies according to the phenomena present. Ulcerations, if indolent, are 
best treated with a solution of sulphate of copper (15 grs. ad 3 j.); whilst, 
if spreading, the progress of the sore can generally be checked with the 
$olid nitrate of silver or acid nitrate of mercury. When there is contrac- 
tion of the passages leading from the pharynx, the canals must be dilated 
with bougies, forced open with dilators, or enlarged by the destructive 
action of galvanic cautery. Dr. Rothenburg ' has also recommended ex- 
cision of a portion of the cicatricial tissue. The use of bougies is, per- 
haps, on the whole the most satisfactory method of treatment, as forcible 
extension or destruction of tissue is generally soon followed by fresh 
cicatrization. In any case, however, though great relief can be afforded 
to the patient as long as he remains under treatment, no cure can be pre- 
dicted, as the stenosis always returns when mechanical measures are sus- 
pended. 



PHTHISIS OF THE PHARYNX. 

Latin Eq. — Phthisis pharyngea. 
E)*encJi Eq. — Tuberculose miliaire de la gorge. 
German Eq. — Miliartuberculose des Pharynx. 
Italian Eq. — Tubercolosi miliare della faringe. 

Definition. — Ulcerations and deposits of miliary tubercle arising in the 
pharynx either as primary local manifestations of constitutional phthisis, 
or secondary to similar phenomena occurring in the lungs, larynx, or 
other organs of the body. 

History. — Within the last fifteen years there has been a growing ten- 
dency to recognize certain conditions of the pharynx accompanied by ul- 
ceration as intimately connected with the tubercular diathesis, and to dif- 
ferentiate the obscure phenomena sometimes met with in other affections, 
especially syphilis. The subject of pharyngeal phthisis had been touched 
on by Green, 2 Bryk, 3 Rindfleisch, 4 Wendt, 6 and Long Fox, 6 etc.; but the 

1 Wien. Medizin Presse, 1876, No. 33. 

2 Practical Treatise on Pulmonary Tuberculosis, New York, 1864. 

3 Wien. Med. Wochensch., 1864, xiv. Nos. 42, 44. 

4 Lehrbuch d. path. Gewebelehre, Leipzig, 18. .'9, p. 310. 

5 Arcliiv. d. Heilkunde. xi. p. 506. 

6 Clinical Observations on Acute Tubercle, St. George's Hosp. Reports, 1869, vol. iv. 



PHTHISIS OF THE PHARYNX. 71 

symptoms and pathology of the disease were first accurately described by 
Isambert, 1 and subsequently so thoroughly elucidated by Friinkel, 2 that 
but little remains to be added to our clinical knowledge of the malady. 

Etiology. — The etiology of tubercular disease of the pharynx is the 
same as that of phthisis pulmonalis, viz., heredity or depression of the 
vital powers resulting most frequently from breathing impure air, or from 
insufficient nutriment, or residence in a cold, damp climate. The data 
furnished by the cases observed up to this time do not, however, satisfac- 
torily explain why the pharynx should, in certain instances, become the 
site of tuberculosis. Almost all of the patients were simultaneously 
affected with pulmonary phthisis, but by their own statements their at- 
tention had first been arrested by a progressively increasing soreness of 
the throat. In one case, however, reported by Isambert, 3 the subject 
being a female child, set. 4^-, no pulmonary symptoms could be detected, 
although the condition of the pharynx was typical of tubercular disease. 
Fninkel, as a result of his own observations, remarks that the patients 
seen by him " had not previously suffered from chronic affections of the 
pharynx, and no ground can be found for assuming that, in them, the 
pharynx was a locus minoris resistentke. There was no hyperplasia of 
the tonsils, nor any condition of the pharynx or fauces, which would en- 
title me to assume that a cheesy deposit was present here." He, there- 
fore, proposes to leave the question of etiology open for the present. 

Symptoms. — Patients suffering from pharyngeal phthisis exhibit the 
same succession of symptoms as those which are characteristic of ordinary 
consumption — the throat affection being probably only an accidental com- 
plication. The lungs, if not at first diseased, soon become affected; 
cough, expectoration, anorexia, hectic, and progressive debility super- 
vene, and, finally, death ensues from exhaustion. Subjectively, the most 
prominent symptom of pharyngeal phthisis is the pain in the throat. 
The odynphagia is always great, so much so that Isambert concludes that 
the pain in deglutition is more severe in this than in any other affection 
of the part. 4 Thus, the first symptom — prior to cough, expectoration, 
increasing debility, etc. — which leads the patient to believe that there is 
anything the matter with him, is often persistent soreness of the throat. 
This phenomenon once established increases pari passu with the develop- 
ment of the local morbid action, and contributes much toward hastening 
a fatal termination. Severe stabbing pain in the ear during deglutition 
is also frequently complained of. According to Frankel, 5 the fever pres- 
ent in tuberculosis of the pharynx shows an unusually irregular course. 

It is, in fact, the fever of acute miliary tuberculosis characterized by 
variable evening temperatures, often up to 104° Fahr., and rising in some 
instances as high as 107.06° Fahr. In one of Frankel's cases, the curve 
of temperature resembled at first that seen in typhus, and afterward that 
of hectic. In another, the temperature of continued fever (100.4° Fahr. 
to 101.2° Fahr.) was sustained, when it rose suddenly to 107.06° Fahr., 
and at the patient's death the thermometer registered 103.1° Fahr. 

Objectively, the appearances presented by tubercular lesions of the 
pharynx are highly characteristic. The ulcers generally begin on the 
lateral walls of the pharynx, and spread thence to the roof of the mouth, 

1 Annal. des Mai. de fOreille et du Larynx, t. ii. p. 162. 

a London Med. Record, January 13 and February 15, 1877, and Berl. Kl. Woch., 
Nov. 1876. 

* Loc. cit. p. 168. 4 Loc. cit. January 15, p. 2. 5 Loc. cit. 



72 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

and the posterior wall, as well as to the velum palati. They are of a len- 
ticular shape, and according to 0. Weber ' bear a great resemblance to 
the corresponding intestinal affection. He describes them as possessing 
" a caseous, broken-down floor, with undermined hypenemic edges, in 
which new tuberculous deposits are imbedded in various stages of devel- 
opment. These rapidly disintegrate, and cause necrosis of the mucous 
membrane lying between them." In the neighborhood of the ulcers, gray 
nodules of the size of millet seeds often spring up, and ultimately break 
down so as to form fresh ulcerations. According to Frankel, a disposi- 
tion to hypertrophy coexists with the destruction of tissue; and in the 
vicinity of the tonsils, especially, polypoid excrescences often arise from 
the ulcerated base. If the uvula becomes affected it may be enlarged to 
the thickness of the thumb. Tumefaction, when present, is, as Isambert 
remarks, not due to an ordinary oedematous condition, but to an infiltra- 
tion of the tissues by a kind of gelatinous matter, which shows no ten- 
dency to escape when scarification is practised. The tendency of the af- 
fection, however, is to cause wasting of those parts which do not become 
the actual seat of the morbid deposit, and, in some cases, the uvula is 
seen to be atrophied instead of being enlarged. When ulceration at- 
tacks the epiglottis, the process of destruction often reduces that organ 
in a short time to a mere stump. The disease in most cases spreads to 
the upper part of the larynx, but as a rule does not extend further down 
than the ventricular bands, and does not give rise to caries of the carti- 
lages. It is worthy of note that the post-mortem examination of the 
cases of pharyngeal phthisis hitherto met with, has not revealed any tu- 
bercular deposit, or ulceration of the oesophagus. In nearly every case 
of tuberculosis of the pharynx, there is enlargement of the cervical glands 
which, in many instances, attain the size of a walnut. 
The following cases 2 serve to illustrate the disease: — 

" Mrs. M. C, a married woman, vet. 29, came under my care on Janu- 
ary 14, 1877. Her family history was bad, her mother and only brother 
having died of consumption. She had always been delicate, but had two 
healthy children, and there was not a trace of syphilis in the mother, or 
either of the children. In October, 1876, she first experienced pain in 
swallowing, and in the November following the glands on both sides of 
the neck became slightly enlarged. Since October she had suffered very 
much from feverishness, especially at night, when she always became very 
thirsty. On examination she was found to be much emaciated, and there 
was evidence of softening of the apex of the left lung. On examining 
the throat, small ulcers were seen covering the palate and the right pos- 
terior pillar of the fauces, whilst the whole of the back wall of the pharynx 
was studded with small ulcers, varying in size from a pin's head to a split 
pea. The uvula was an inch in length ; on the right side of the neck one 
gland was as large as a pigeon's egg, and there were two other indurated 
glands, each about the size of a filbert nut. The epiglottis was of a pale 
color, and much thickened, and presented a turban-like appearance. 
There were superficial ulcers occupying its right half. The ary-epiglottic 
fold was swollen, and presented a pyriform appearance. The right ven- 
tricular band was also thickened and ulcerated. The vocal cords were 
slightly thickened, and the vocal processes of both cords ulcerated. The 



Handb. d. Allgem. u. Spec Chir. Pitha u Billroth. Bd. iii. p. 360. 
See also Dr. Gee's cases : Barth. Hosp. llsports, vola. vii. and ix. 



PHTHISIS OF THE PHARYNX. 73 

patient remained under my care for three weeks, and during this time no 
marked change took place in the appearances described; three small 
ulcers, however, formed at the back of the tongue, and the anterior pil- 
lar (of the fauces) on the right side became ulcerated. The patient was 
treated with soothing inhalations (vapor benzoini and vapor conii: Throat 
Hospital Pharmacopoeia), but they failed to relieve pain, which was very 
marked. She subsequently obtained great relief from the insufflation of 
morphia, but I heard that she died early in March. 

" In November, 1876, a young lady, set. 15, was brought to me on ac- 
count of great difficulty in swallowing. Her father had been under my 
care some years previously for laryngeal phthisis, from which he had ulti- 
mately died; the rest of the family were healthy. This patient had en- 
joyed good health until the previous June, when she was accidentally im- 
mersed in a river, took cold, and lost her voice. On examination she was 
found to be very thin and weak; there was marked dulness at the apices 
of both lungs, but no evidence of softening. The whole of the pharynx 
was found to be studded with minute ulcerations, which, however, were 
most marked on its posterior wall. The uvula was greatly thickened, but 
very little elongated; it had a kind of brawny consistence, and was not 
at all cedematous. There was a fringe of small excrescences extending 
along the pillar of the fauces on the right side. The epiglottis was so 
much thickened that it was impossible to obtain a view of the larynx. In 
this case the evening temperature at 9.30 was for several nights 104°, and 
on one occasion 106°. The patient, after remaining under my care for 
three weeks, and deriving considerable relief from insufflation of morphia 
twice a day, left England to pass the winter at Cannes, but took cold in 
Paris, and died in a few days." 

Pathology. — At the necropsy of a case reported oy Frankel, 1 ulcers 
were found on the lateral walls of the pharynx, on the roof of the mouth, 
on the nasal portion of the posterior wall of the pharynx, and on the 
velum, while they ceased abruptly at the commencement of the oesophagus. 
On microscopic examination the base of the ulcer is found to be occupied 
by a thick infiltration of round cells, which extend deeply into the sub- 
mucous tissue, even as far as the muscles, which, at these parts, present 
the transverse striae less distinctly than usual. The round cells infiltrate 
the connective tissue of the glandulae, but do not invade the special gland 
cells, which are generally in a state of fatty degeneration. The latter 
have a great tendency to become cheesy, and portions of cheesy matter 
often lie among the round cells. Isolated gray nodules are rare. In 
FriinkePs case, above referred to, both lungs exhibited cheesy broncho- 
pneumonia, and an abundance of gray nodules; in the left lung there was 
a cavity as large as a hen's egg. There were also tubercles in the pleura, 
liver, and spleen, and tuberculous ulcers in the intestines. In other cases 
miliary tubercle was found in the choroid membrane and in the kidneys, 
prostate, thyroid body, etc. 

Diagnosis. — Tuberculosis of the pharynx appears to have been gene- 
rally confounded with syphilis, and to this fact the comparatively scanty 
amount of clinical observations is probably due. I can recall many cases 
which, in former years, I put down as tuberculo-syphilitic disease, but 
which I have no doubt now were instances of pharyngeal phthisis. Now 
that the disease has been so carefully described, it will be seen that there 

1 Loc. cit. p. 1. 



74 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

are many points of difference between the two maladies; and the observ- 
ant practitioner, when once warned, will not be likely to make an error 
in diagnosis. The lenticular ulcers of pharyngeal phthisis, with the de- 
velopment of gray nodules in their neighborhood, are extremely charac- 
teristic, and when once seen can always afterward be readily recognized. 
The history of the individual cases will usually afford considerable aid to 
diagnosis, but it must not be forgotten that syphilis and tuberculosis may, 
in some instances, coexist. Should tubercle of the choroid be present, 
as occurred in one of FrankePs cases, we are justified in assuming that 
there is general miliary tuberculosis. The fact that, in most cases, the 
pharyngeal symptoms first attract the patient's attention, is of positive 
value in arriving at a diagnosis. 

Prognosis. — Tuberculosis, when manifesting itself in the pharynx, runs 
a more rapid course than ordinary pulmonary phthisis. Thus, in all the 
recorded cases, death occurred in a period varying from two to six months. 
In none of the cases has recovery taken place, and it is probable that the 
pharyngeal lesions indicate such an extensive implication of all the struc- 
tures of the body with tuberculosis, that the issue must necessarily be 
fatal. It is, however, unquestionable, that death ensues more rapidly in 
some cases than in others ; and, for this reason, Cornil ' and Isambert ' 2 
have come to the conclusion that there are two varieties of pharyngeal 
tuberculosis, viz., an acute, and a chronic, form. As the disease almost 
always terminates fatally in six months, this distinction is scarcely well 
founded. A certain modification in our prognosis as to the duration of 
disease may, however, be required in different cases. 

Treatment. — As Frankel 3 observes, the recognition of tuberculosis of 
the pharynx is more creditable to our diagnostic acumen than to our ther- 
apeutic skill. But small results can be hoped for from either local or 
constitutional measures in such cases. The administration of cod-liver 
oil with a general tonic and analeptic treatment may be attended with 
some slight benefit, and the life of the patient may be prolonged for a 
short time. Almost all writers agree in discountenancing the application 
of astringent or caustic solutions to the ulcerated surfaces. Isambert 
states that he has found some advantage from the local use of glycerole 
of morphia. When the pain is great, sedative remedies may indeed be 
employed as palliatives, especially in order to lessen the difficulty of swal- 
lowing. With this view insufflations of acetate of morphia, gr. ^ to gr. -J- 
once or twice daily, mixed with powdered starch, and hot soothing inhala- 
tions, can often be used with decided benefit; whilst in the worst cases 
recourse must also be had to nutritive enemata. 

1 Journal des Connaissances Medicales, July, 1875, p. 193. 

2 Loc. cit. p. 164. 3 Loc. cit. p. 48. 



TKAUMATIC PHARYNGITIS. 75 



TRAUMATIC PHARYNGITIS, 

Latin Eq. — Pharyngitis traumatica. 
/*/•< nch jEfy.— Pharyngite trauinatique. 
German Eq. — Traumatische Schlundentziindung. 
Italian Eq. — Faringite traumatica. 

Definition. — Acute, often cedematous, inflammation of the pharynx, 
caused by swallowing boiling water or caustic substances, inhalation of 
flame, etc. 

Etiology. — Traumatic inflammation of the pharynx is most commonly 
met with in children, as the result of an attempt to drink boiling water 
from the spout of a kettle. 1 Swallowing corrosive liquids, either acci- 
dentally or purposely, is also a common cause of the malady. In many 
of such cases, however, the symptoms of the pharyngeal injury are lost 
in the graver phenomena arising from oedema of the glottis or severe 
lesion of the alimentary canal. Inflammation of the pharynx is sometimes 
caused by the inhalation of hot air or flame, as may occur to persons who, 
in the case of fire, are obliged to remain for some time in the burning 
building before being rescued. 2 

Symptoms. — Pharyngitis, as the result of any of the above causes, is 
accompanied by all the signs of intense inflammation, with extreme odyn- 
phagia and urgent dyspnoea. The morbid process may terminate in sup- 
puration of the connective tissue of the neck, 3 and even in gangrene of 
the affected parts, but, according to Bamberger, 4 the latter issue is an ex- 
tremely rare one. In many instances of this kind of injury the pharyn- 
geal affection is almost unimportant, as forming merely a part of a deep 
and extensive inflammation which involves the larynx and oesophagus. 
With respect to corrosive poisoning, the symptoms produced by the vari- 
ous drugs that act in this way have a considerable resemblance, and ac- 
curate conclusions as to the particular poison can seldom be arrived at in 
individual cases without a chemical analysis of the contents of the stom- 
ach, etc. The following details may, however, be given as to the physical 
condition of the pharynx when acted upon by those caustic substances 
most commonly swallowed by accident or taken with suicidal intent. 

SnI pit uric Acid. — At first the mucous membrane of the mouth and 
pharynx presents a parchment-like aspect, or looks as if it had been smeared 
with thin arrowroot. 5 Gradually it becomes darker, and, turning to a 
brownish color, separates in shreds or extensive layers. When the ves- 
sels are reached, the blood is charred and resembles blacking. 7 The pain 



1 See a paper on this subject by Jameson : Dublin Quart. Journ. of Med. Sc., Feb- 
ruary, 1848 ; and a more recent one by Bevan : Dublin Med. Journ., November, 18GG. 

- Solis Cohen : Inhalation, its Therapeutics and Practice, p. 294 (Report on ten 
patients), Philadelphia, 1867. 

3 Stroppa : Ga^etta Lombarda, No. 35, 1871. 

4 Handb. d. Spec. Path. u. Therap., Bd. vi. Abth. i. p. 10. 

5 Taylor On Poisons, p. 178, London, 1875. 

6 In a case seen by Galtier (Toxicologic, vol. i. p. 199), a piece of mucous mem- 
brane representing- the entire lining of the gullet for a distance of nine inches was 
expelled at once. 

1 See a case by Gull : Med. Gaz., 1850, vol. xlv. p. 1102. 



76 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

is severe, but sometimes does not come on for several hours after the poi- 
son has been swallowed. 

Nitric Acid acts much like sulphuric acid, but the pain is almost 
always an immediate symptom. The mucous membrane is whitish and 
soon becomes of a citron color, especially over the tonsils. 

Hydrochloric Acid. — The mucous membrane is highly inflamed, but 
otherwise does not show much alteration. The surface of the tongue is 
generally reduced to a pulp. 

Oxalic Acid. — The mucous membrane looks white and softened, and 
the small vessels are filled with blackened blood. According to Christi- 
son, 1 this acid acts as a poison independently of its corrosive properties, 
by causing paralysis of the heart. 

Carbolic Acid causes the mucous membrane to become white, corru- 
gated, and hardened. 

Caustic Potash and Soda have very similar effects, and are not un- 
frequently taken in the form of soap lees. The mucous membrane is soft- 
ened, detached, and inflamed, whilst numerous patches of a chocolate 
color, almost black, are perceived. In a case seen immediately after its 
occurrence by Dr. Deutsch 2 the mucous membrane was of a bluish red 
color, bled on being touched, and separated quickly in shreds. 

Caustic Ammonia acts much in the same way as potash or soda, with 
this difference, that the^>«m is immediate, and much greater in severity. 
The mucous membrane is blackened. 

Phosphorus acts as a general irritant, and also causes redness of the 
mucous membrane of the throat. The breath has a strong odor of garlic. 

Tartar Emetic causes soreness of the mouth and throat, with aph- 
thous-like crusts, which are at first white, but afterward become brown 
or black. 

Chloride of Zinc (in tne form of Burnett's disinfecting solution) has 
a strongly corrosive action on the mucous membrane of the throat, which 
is white and thickened, and has a strongly destructive action. 

Corrosive Sublimate causes the mucous membrane to become white 
and shrivelled, and gives rise to violent throat symptoms, almost immedi- 
ately on being taken. 

Arsenic acts as a general irritant and has no corrosive action, whilst 
the symptoms of poisoning do not come on for some time after the dose 
has been taken. 

Nitrate of Silver. — The whitish appearance of the mucous membrane, 
when touched by this substance, is well known. It acts as a powerful 
local irritant. 

Muriated Tincture of Iron causes inflammation and swelling of the 
mucous membrane, and distressing urinary symptoms. 

Various saline substances, such as nitrate of potash, oxalate of2)otash, 
salts of lead or copper, etc., cause inflammation in the pharynx when taken 
in concentrated forms, and act as powerful poisons. 

Prognosis. — The prognosis, of course, depends on the amount of in- 
jury done to the tissues of the pharynx, larynx, and oesophagus, and on 
ihe constitutional effects produced by the poison. In slight cases where 
the pharynx alone has been touched by the local irritant, Jhere is gener- 
ally a good prospect of recovery, but always a risk of subsequent contrac- 
tion of the pharynx. If the larynx is affected, there is danger of imme- 
diate death from oedema of the glottis and asphyxia. Should the cesoph- 

! On Poisons, p. 219. 2 Berliner Med. Zeitung, No. 51, 1857. 



ANGINA CAUSED BY POISONOUS DRUGS. 77 

agus be much injured, the prospects of a fatal termination are usually 
more remote, but not less certain, from stricture of the gullet and ma- 
rasmus. 

Treatment. — It does not come within the scope of this article to indi- 
cate the various remedies that may be administered as antidotes, in order 
to neutralize the caustic effects of corrosive substances. It may be use- 
ful to mention, however, that as the action of the irritant poisons is very 
rapid, but little benefit can be expected from drugs which have the prop- 
erty of rendering them chemically inert when in a free state. 

The best treatment that can be pursued in cases of traumatic pharyn- 
gitis, is one of a purely anodyne and emollient character. Opium or 
morphia should be given in full doses by the mouth or hypodermically, 
whilst the local medication of the part is best effected by the insufflation 
of morphia, gr. \ to gr. ^ twice or three times a day. Hot, soothing in- 
halations (Throat Hosp. Phar.) may also be used with advantage, but 
gargles are usually inadmissible, as the least movement of the fauces 
causes severe pain. The difficulty of feeding the patient is often great, 
owing to the intense odynphagia, whilst an oesophageal tube cannot be 
used because the softened state of the tissues renders perforation of the 
gullet by the instrument almost unavoidable. As soon as the sloughs 
have separated, and the diseased surface has assumed the character of 
healthy ulceration, the mucous membrane can be brought into a healthy 
state by the application of astringent solutions, such as the pigmenta of 
iron, zinc, or nitrate of silver. 1 



ANGINA CAUSED BY POISONOUS DRUGS. 

Latin Eq. — Anginae venenis ortae. 

French Eq. — Angines toxiques. 

German Eq. — Toxische Anginen. 

Italian Eq. — Angine eccitate da droghe velenosi. 

Definition. — Morbid conditions of the pharynx caused by the action 
of mineral or vegetable poisons taken internally. 

1. Mercury. — Amongst the ill consequences sometimes arising from 
impregnation of the system with mercury is a species of pharyngeal in- 
flammation characterized by redness of the mucous membrane, ulcers with 
a grayish colored surface, and considerable dysphagia. At the same time 
the mouth and tongue are generally similarly affected, and ptyalism is 
usually present. This disease is most commonly met with in gilders, in 
persons employed in quicksilver mines, and in patients who have under- 
gone medical treatment. The history of the case affords the best aid to 
diagnosis, and the local lesions generally yield after a time to the use of 
astringent gargles, and the internal administration of chlorate of potash 
— provided, of course, that the cause of the affection has been removed. 

2. Antimony. — Tartrate of antimony, when given constantly for a few 
days in a concentrated form, has a very irritating effect on the mucous 

1 Throat Hosp. Phar. 



78 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

membrane of the pharynx. The patient complains of heat, and a painful 
sense of tension in the throat, whilst swallowing is rendered extremely 
difficult. On inspection the pharynx appears red and swollen, and often 
covered with aphthous ulcers. A like condition generally prevails at the 
same time in the mouth. Spontaneous resolution occurs in a few days 
after the administration of the remedy has been discontinued. The affec- 
tion should be treated by gargles containing alum, sulphate of zinc, or 
hydrochloric acid, whilst the occurrence of the accident may be prevented 
by exhibiting the antimony in the form of pills. 

3. Iodide of Potassium. — This drug exerts a special effect over the 
mucous membranes of the nose, conjunctivae, and pharynx. In some per- 
sons, as is well known, a single small dose is sufficient to cause a violent 
coryza with incessant sneezing, and a sensation of painful tension and 
dryness in the throat. These symptoms are occasionally accompanied by 
salivation, and there is sometimes slight odynphagia. The attack resem- 
bles, in a considerable degree, an exacerbation of influenza, but in some 
cases the phenomena are almost confined to the pharynx and the salivary 
glands. On inspection no lesions are discernible, beyond superficial red- 
ness of the mucous membrane, and the affection subsides spontaneously 
on suspension or diminution of the dose of the remedy. The injection of 
tincture of iodine into a serous cavity is capable of producing a similar 
set of symptoms. 

4. Arsenic, Copper, Lead, Zinc, etc. — The salts of all these metals, 
when taken as medicines, or introduced in any way in small doses into 
the system, have more or less power of causing hyperaemia and superficial 
inflammation of the mucous surfaces. 

5. Belladonna. — This vegetable, as well as most of the other members 
of the natural family of Solanacese, is capable, when taken in an over- 
dose, of producing painful throat symptoms. Heat in the pharynx and 
difficulty of swallowing are present, and there is considerable congestion 
of the mucous membrane. These phenomena are accompanied by dilata- 
tion of the pupils, and more or less disturbance of the intellect. The con- 
dition should be met by the use of emollient and sedative gargles, and 
when there are general symptoms of intoxication, by the use of stimulants 
— especially strong coffee. 



WOUNDS OF THE PHARYNX. 

Latin Eq. — Vulnus pharyngis. 
French Eq. — Plaies du pharynx. 
German Eq. — Wunden des Schlundes. 
Italian Eq. — Ferite della faringe. 

Definition. — Solutions of continuity of the walls of the pharynx caused 
by violence. 

Etiology, Symptoms, etc. — The pharynx is chiefly liable to be wounded, 
in suicidal and homicidal attempts, when the throat is cut or stabbed. 
Wounds inflicted by drawing a knife across the throat are almost always 
situated below the live-id bone, as above this level the fleshv base of the 



WOUNDS OF THE PHARYNX. 79 

tongue intervenes so as to prevent the instrument penetrating so far as 
the pharyngeal cavity. The wound is often in the thyro-hyoid space, and 
not unfrequently the epiglottis is partially divided. Profuse hemorrhage 
from some of the numerous large vessels generally occurs, and the inci- 
sion gapes considerably, especially if the head is raised. Mucus, saliva, as 
well as blood, escape from the wound, and attempts at deglutition are fol- 
lowed by the extrusion of part or even the whole of the ingesta through 
the aperture. 1 Dysphagia is present from the first, but there is seldom 
any dyspnoea or alteration of voice, unless the larynx is simultaneously 
injured or subsequently becomes implicated by extension of inflammation. 
It is just possible, however, that a severed fragment of the epiglottis 
or one of the arytenoid cartilages may drop into the larynx, and act as a 
foreign body. 2 Should there be much hemorrhage into the pharynx, the 
blood may pass into the air-passages and speedily give rise to fatal as- 
phyxia. ... 

Wounds of the pharynx sometimes occur in a direction from within 
outward, articles held in the mouth, such as pipe-stems, pen-holders, pen- 
cils, spoons, etc., being accidentally driven violently backward and thrust 
through the walls of the cavity. 3 

Treatment. — The first object to which we must direct our attention is 
the arrest of hemorrhage, if such be present. When the bleeding is con- 
siderable, and cannot be restrained by pressure, it may be necessary to 
cut down upon, and ligature, one of the carotid arteries. If there be no 
accompanying wound of the air-passages, the edges of the incision may 
be united by sutures, whilst the head is maintained in a suitable position 
by means of pillows, bandages, and plasters. When a portion of the 
epiglottis is partially severed it is advisable to remove it entirely, rather 
than to attempt to unite it by sutures, as absence of this organ is at- 
tended by little functional inconvenience. Should oedema of the glottis 
occur, it will of course be necessary to resort to tracheotomy. During 
cicatrization of the pharyngeal wound the patient must be fed by the aid 
of a tube passed into the upper part of the oesophagus. If this mode of 
giving food occasions spasm of the glottis, and irritates the throat gener- 
ally, it is advisable to administer nourishment to the patient by means of 
nutritive enemata. Perfect rest of the parts is thus almost secured, and 
the dangers of such cases are materially lessened. Should extensive 
traumatic inflammation of the pharynx occur, it must be treated on gen- 
eral principles. In all cases of wounds of the pharynx, where the act of 
deglutition is not contraindicated, the continual sucking of ice is a good 
local safeguard against subsequent inflammatory action. 



1 Moore : The Lancet, 1864, vol. ii. p. 287. 

2 Gant : The Science and Practice of Surgery, London, 1871, p. 828. 

3 Macleod : Cooper's Diet, of Pract. Surg., London, 1872, vol. ii. p. 452; Med.- 
Chirurg. Transact. , voL xxix. p. 38 ; and Durham : Holmes 1 System of Surgery, vol. 
ii. p. 457. 



80 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



FOREIGN BODIES IN THE PHARYNX. 

Latin Eq. — Corpora adventitia in pharynge. 
French Eq. — Corps etrangers dans le pharynx. 
German Eq. — Fremdkorper im Schlundkopf. 
Italian Eq. — Corpi stranieri nella faringe. 

Definition. — Foreign bodies introduced into the pharynx from with- 
out, and arrested there by being lodged in recesses, or by becoming im- 
pacted in a wall of that cavity. 

Etiology. — Foreign bodies often become arrested in the pharynx. 
The substances which have been most frequently found lodged there are 
lumps of meat, fragments of bone, and entire fish-bones, bristles, leeches, 
false teeth, buttons, coins, pins, and needles. I have, at different times, 
removed every one of the bodies named, except leeches. Occasionally 
persons are met with who appear to have a special predisposition to the 
lodgement of foreign bodies in the pharynx, resulting either from careless- 
ness in eating, impaired sensibility of the mucous membrane, or from some 
unusual irregularity of the walls of the plrarynx, which causes substances 
to be easily entangled and arrested. Large foreign bodies generally be- 
come lodged at the lower part of the cavity, where the cricoid and aryte- 
noid cartilages project backward, or between the base of the tongue and 
the epiglottis. Small and sharp pointed bodies may become fixed at any 
part of the pharynx, but are usually found sticking into the tonsils, 
which, on account of their uneven surface, are especially likely to arrest 
passing substances; small substances may also be entangled in the pillars 
of the fauces, or in the lateral folds of the cavity. Sometimes a large or 
long body, as a needle or fish-bone, is found stretching across the entire 
width of the pharynx. With respect to leeches, these animals have gen- 
erally found their way into the throat in the case of travellers who, being 
overcome by thirst, have been obliged to drink ditch-water. Numerous 
instances of this kind, accompanied by sudden and alarming symptoms, 
have been observed and reported by practitioners from a very early date, 
Hippocrates himself giving detailed advice as to the proceedings to be 
adopted in such a contingency. 1 

Symptoms. — Small pointed substances generally occasion much dis- 
comfort, especially during deglutition, although respiration is not inter- 
fered with unless considerable inflammation is set up. Fragments of hard 
substances, such as bone, may cause ulceration or abscess of the pharynx, 2 
but they more often merely give rise to localized inflammation and 
troublesome irritation. When an abscess occurs fistulous openings may 
be formed in the neck, through which the foreign body may eventually 
be expelled. Foreign bodies sometimes give rise to great danger, and 
may even cause death from perforation of a large blood-vessel, or the 
foreign body may penetrate the intervertebral substance and cause caries 
of the bodies of the vertebrne. 3 Bell 4 has reported the case of a lad who, 



1 Breschet : Diet, des Sciences Med., 1813, vol. vii. p. 10. 
8 Moore : Loc. cit. 

3 Fleury et Schupfe : Nouveau Diet, de Med. et de Chir., vol. i. p. 297. 

4 Medical Gazette, 1842-43, p. 694. 



.FOREIGN BODIES IN THE PHARYNX. 81 

having swallowed a sewing needle with his food, died on the tenth day 
afterward from hemorrhage. At the autopsy the needle (three inches 
long) was found fixed transversely across the pharynx, the wall of 
which it had perforated opposite the middle of the thyroid cartilage 
whilst the point was lying in the common carotid artery. The larynx, 
trachea, and stomach were found filled with clotted blood. A somewhat 
similar case is related by Fingerhuth, 1 in which a piece of the stem of a 
long tobacco pipe became lodged in the side of the pharynx, and after an 
interval of eight months occasioned fatal hemorrhage by wounding the 
carotid ill a sudden movement of the head. In some cases swallowing 
becomes so painful that deglutition is rendered almost impossible. When 
a large foreign body is impacted in the pharynx, the chief danger arises 
from the probability of suffocation on account of the entrance to the 
larynx being obstructed. In rare instances the foreign body may become 
impacted in such a way as to press down the epiglottis and occasion sud- 
den death. In such a case the patient appears to die in a fit of apoplexy. 

If a patient complain of a foreign substance being arrested in the 
pharynx, a view of the parts can sometimes be obtained by placing the 
individual with his mouth open opposite a window, directing him to take 
a forcible inspiration, and pressing down the tongue with the finger. In 
most cases, however, the laryngoscope must be made use of, as by this 
appliance alone is it possible, to inspect the whole of the pharyngeal 
cavity. When the parts are thoroughly examined in this way, it is rare 
that a foreign body, however small, escapes notice; but when nothing 
can be seen, further examination should be made with the finger, as it is 
possible that a small, pointed, semi-transparent body, such as a fish-bone 
or bristle, may in this manner be detected. Even coins have been discov- 
ered imbedded in the folds of mucous membrane which pass from the 
sides of the pharynx to the larynx, after having remained undetected for 
a considerable time in this position. 2 Thus a case is recorded in which a 
halfpenny remained in the pharynx of a child eight months, and was 
ultimately brought up after a fit of coughing. 3 In rare instances foreign 
bodies may get into the pharynx by penetrating the structure of the 
neck. In illustration of this fact an instance is on record in which a sur- 
geon removed from the pharynx of a woman a sewing needle, which had 
been thrust into her neck half an hour previously. 4 

Diagnosis. — The history of the case, and inspection of the pharynx, 
will generally afford conclusive evidence as to the nature and position of 
the foreign body. It must be remembered, however, that the substance 
may sometimes have been swallowed or ejected a short time after its 
lodgement, though the patient may still continue to experience a sensation 
as if something were sticking in his throat. When the pharynx is unusu- 
ally sensitive, or especially when a particular spot on its walls is in an 
irritable condition, a patient after taking food is very likely to imagine 
that something has become fixed in the throat. Hysterical women are 
particularly prone to become possessed with such an idea, and to persist 
in it for weeks or months in spite of all assurances as to the groundless- 
ness of their delusion. Again, with respect to children, serious symp- 
toms, due to the impaction of a foreign body in the throat, may be pres- 

1 Preuss. Vereinszeitung, N. F. vii. No. 23, 1864. 

2 Durham : Holmes 7 System of Surgery, vol. ii. p. 519. 

3 Ogier Ward : Trans. Path. Soc, 1848-49. 

4 Jardine Murray : Med. Times and Gazette, 1859, p. 468. 
G 



82 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

ent, whilst the history of the case does not afford the slightest clue to 
the origin of the phenomena. 

Prognosis. — If the foreign body can be removed, the prospect is of 
course perfectly satisfactory, but if it remain in the throat, the prognosis 
must depend on its size and nature. Thus a large body may threaten 
death from suffocation, and a small one may give rise to a fatal result by 
penetrating a vital part. A sharp body, such as a bone, is more danger- 
ous in its remote consequences than a smooth one. Rokitansky ' thinks 
that the impaction of small hard bodies, such as cherry stones, at the 
lower part of the pharynx may cause the formation of a diverticulum. 

Treatment. — The pharynx being as thoroughly accessible to instru- 
ments as it is to vision, foreign bodies, lodged in its cavity, can gener- 
ally be easily removed. Large pieces of soft substances, such as lumps 
of meat, may be seized with the fingers or with forceps and extracted, or 
they may be pushed down into the gullet with a probang. Coins can be 
removed with forceps, or if they are impacted at the orifice of the oeso- 
phagus the money-probang may often be used with success. Small 
pointed bodies, such as fish-bones, bristles, pins, etc., imbedded in the 
substance of the tonsils, or entangled in the folds of mucous membrane, 
are best seized by suitable forceps, and drawn out in the direction of their 
long axis. Plates of artificial teeth can usually be most easily extracted 
by the aid of forceps. When summoned to a patient who is almost suf- 
focated, it may not be possible to make a thorough exploration of the 
throat, and tracheotomy may be immediately necessary. The common, 
but fatal, practice is at once to use a probang, and to force the obstruct- 
ing object onward. A foreign body, comparatively harmless in the 
pharynx, is thus often driven into the larynx or even into the bronchi, or 
may become impacted in the oesophagus. 2 At the same time great in- 
jury is often done to the soft parts. If the patient's respiration could 
support a jDrobang, an inspection could certainly be made; but if he ap- 
pear to be dying of apnoea, tracheotomy may be necessary before the ex- 
traction of the foreign body can be accomplished. When no foreign 
substances can be detected after careful examination, it is advisable, even 
though the patient's sensations lead him to believe that the cause of his 
trouble is not removed, to wait for some little time before subjecting him 
to further manipulation. For the sensations of the patient are often un- 
reliable, and although the foreign substance may have been extracted, a 
feeling of heat, pricking, or constriction in the pharynx, may be expe- 
rienced for some time afterward. Such sensations deceive the sufferer 
by simulating the presence of some offending substance. By leaving 
the parts at rest, if there be any foreign body in the pharynx, it will often 
work its way out, and be swallowed or ejected by the mouth, or it can be 
subsequently removed. As a rule, the sensations which remain after the 
extraction of a foreign body, generally subside in a few hours, although 
in some cases they persist for several months, and cause the utmost mis- 
ery. There is usually some hyperemia, and probably also a morbid con- 
dition of the terminal nerve-fibres. Such cases are frequently difficult to 
cure. The application, however, of astringents to the mucous membrane, 
and the employment of galvanism, usually relieve the symptoms after a 
time. In some instances change of air and scene is necessary in order t6 
dispel the impression, and travelling should be recommended. In ordi- 



1 Pathological Anatomy (New Syd. Soc. Trans.), vol. ii. p. 12. 

2 SchrOtter : Medical Examiner, March 23, 187G. 



NEUROSES OF THE PHARYNX. 83 

nary cases the discomfort remaining after the removal of a foreign body 
from the pharynx will be much alleviated by directing the patient to sip 
a little iced water from time to time, or to suck and swallow small pieces 
of ice. It must not be forgotten that occasionally two foreign bodies — 
especially fish-bones — may be present at the same time in the pharynx 
without the patient being aware that there is more than one substance. 
Hence, if the sensations remain after the removal of the foreign body, a 
further examination should be made. A remarkable instance of this oc- 
curred to me a few years ago. An eminent Glasgow surgeon consulted 
me on account of a fish-bone which had become lodged in his throat three 
or four months previously. I succeeded in removing a fish-bone from the 
lower part of the pharynx. I told him that " he might feel the sensation 
for a day or two, but that there could be nothing more in the throat." 
Two days afterward the gentleman returned to me, saying that he felt 
sure there was another bone near the site of the one I had removed, and 
on making examination I found that his sensations were accurate, and 
that a second bone was lodged in the throat at the spot indicated. On its 
removal, no further unpleasant feelings were experienced. It may be re- 
marked that, between the removal of the first and second bone, the pa- 
tient had not partaken of any fish. 



NEUROSES OF THE PHARYNX. 

Latin Eq. — Neuroses pharyngis. 
French Eq. — Nevroses du pharynx. 
German Eq. — Neurosen des Schlundes. 
Italian Eq. — Nevrosi della faringe. 

Definition. — Disordered sensibility of the mucous membrane of the 
pharynx, or a perverted or impaired action of the pharyngeal muscles, 
due to central or local disease of the nervous system. 

Nervous affections of the pharynx are divided into neuroses of sensa- 
tion and neuroses of motion. 

Neuroses of Sensation. 

Under this head four conditions of the mucous membrane in which 
the sensibility is altered may be grouped, viz., anaesthesia, hyperesthesia, 
paresthesia, and neuralgia. 

Anaesthesia. — This neurosis is generally of little clinical importance, 
but occasionally, according to Krishaber, 1 diminished sensibility is one of 
the earliest symptoms of progressive bulbar paralysis. It is nearly always, 
present in diphtheritic paralysis. In insane patients 2 it may occasionally, 
however, be found to exist without any motor disturbances, or may re- 
sult from the action of certain drugs, such as morphia or chloroform ap- 
plied locally. To cure the affection, galvanism may be applied to the part, 
and strychnine administered internally or introduced hypodermically. 

1 Gazette Hebd., 1872, p. 772. 

* Ziemssen's Cyclopaedia, vol. vi. p. 993. 



64 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

JL/percesthesia. — Abnormal sensibility is of much more frequent occur- 
rence than the affection just described. It is met with very frequently 
in individuals otherwise perfectly healthy, and often forms one of the 
greatest difficulties the laryngoscopist has to contend with in order to 
obtain a view of the interior of the larynx. The introduction of the Eus- 
tachian catheter may also be rendered impossible on account of hyper- 
esthesia in the pharyngo-nasal region. It may be useful to mention 
here that even in the normal condition there is a considerable difference 
in the sensibility of various parts of the pharynx. Thus it is great- 
est on the arch of the palate, whilst the posterior wall of the cavity may 
generally be touched without provoking any reflex action. Every variety 
of hyperesthesia may be met with in hysterical women, whilst an in- 
creased sensitiveness of the parts generally accompanies inflammatory 
conditions, acute or chronic. No special measures are demanded for the 
cure of hyperesthesia of the pharynx, except when the practitioner re- 
quires to pass instruments into the cavity for the examination or local 
treatment of the adjacent parts. These will be described in the article 
on " Laryngoscopy." 

Paresthesia. — This condition may occur without any overt cause in 
hysterical women, but it generally follows the removal of a foreign body. 
The patient complains of something sticking in the throat, such as a hair, 
a fish-bone, or a rough fragment of some hard substance. When this 
morbid sensation is consequent on the previous lodgment of a foreign 
body it generally passes away spontaneously in a day or two; but, some- 
times, it may remain % for months — or even years, as already explained 
under " Foreign Bodies in the Pharynx." When dependent on hysteria, 
the general measures usually adopted for the relief of the complaint 
should be employed. 

Neuralgia. — This affection of the pharynx has not hitherto been ac- 
curately described. Turck, 1 however, mentions some half-dozen exam- 
ples (four occurring in females) where severe pains of the soft palate, 
principally on one side, were complained of. The affection appears to 
have been incurable in one instance, whilst the rest recovered in a few 
weeks under the influence of strong applications of nitrate of silver. Some 
of these cases, however, approached more nearly to simple hyperesthesia 
or paresthesia than to veritable neuralgia. 

Many instances of this disease have come under my notice. In most 
of the cases the patients were young girls under twenty, but I have met 
with the affection in married women between thirty and forty. In some 
of these cases there was anemia, and more rarely chlorosis, but many of 
the patients were otherwise healthy. In most of the cases the patients 
were not in the least hysterical. Sometimes there was local hyperemia: 
sometimes anemia. In the former cases, free scarification proved very 
useful. In nearly all instances applications of tincture of aconite, three 
or four times a day, were of the greatest benefit, and this drug has often 
proved, in my hands, the only remedy w T hich gave relief. 

Neuroses of Motion. 

Spasm. — This symptom is rarely met with except in cases of acute 
oedema of the uvula, intense pharyngitis, and hydrophobia. The con- 

1 Wiener Allgem. Med. Zeitung, No. 9, 1862. 



NEUROSES OF THE PHARYNX. 85 

strictors of the pharynx, however, often participate more or less in spas- 
modic stricture of the oesophagus. Twitching movements of the pal- 
ate, according to Wagner, 1 also occur in advanced cases of paralysis 
agitans. Thus, in a patient suffering from constitutional syphilis and 
paralysis of one half of the body (the palate not being involved), Wagner 
observed movements, synchronous with the pulse, on one side of the 
palate. 

Paralysis. — There are four kinds of paralysis of the palate and pha- 
rynx: — (1) the affection, which is a frequent sequel of diphtheria, and oc- 
casionally met with after common angina; (2) the slight paralysis which 
is sometimes associated with facial paralysis; (3) the loss of power, which 
is one of the most marked phenomena of progressive bulbar paralysis; 
and (4) paralysis of the constrictors of the pharynx, which is always asso- 
ciated with a similar condition of the oesophageal canal. 

Diphtheritic paralysis of the palate is a common sequel of membra- 
nous sore throat. An analogous affection, however, sometimes follows a 
simple angina, and may perhaps arise from mere debility. Cases of the 
former kind have been reported by Drs. Gubler, 3 Broadbent, 3 Hermann 
Weber, Silver, and others; and Dr. Broadbent 4 has recorded an instance 
in which the disease (associated with loss of power of the abductors of 
the vocal cords and slight dysphagia) arose spontaneously in a child six 
years of age. It is probable that inflammatory disease of the pharynx, 
such as tonsillitis, general pharyngitis, putrid sore throat, or syphilis, 
may give rise to more or less disturbance of the motor apparatus of this 
region; but it is only in diphtheria that other nerve-centres suffer, so 
that this fact affords a means of differential diagnosis. The voice acquires 
a characteristic nasal timbre, the modification of certain articulate sounds 
being very characteristic, owing to the impossibility of closing the naso- 
pharyngeal passage. Thus rub, head, and egg become rum, hent, and 
enk.* 

On inspection, the velum pendulum palati and uvula are seen to be 
relaxed, and although during inspiration and expiration the uvula moves 
backward and forward under the force of the current of air, the power of 
voluntarily raising it is, to a great extent, lost. This feature is generally 
unilateral, and when bilateral it always affects one side much less than 
the other, giving rise to a mere paresis of the muscles on the side least 
affected. There is also generally loss of sensibility in the veil of the pal- 
ate. The affection usually comes on about a fortnight after the com- 
mencement of convalescence, and is sometimes followed by general paraly- 
sis or paresis of the muscles of the extremities. The patient first per- 
ceives the difficulty of swallowing, in taking fluids, which frequently 
regurgitate through the nose or pass into the larynx. This symptom is 
partly due to the implication of the depressors of the epiglottis. The 
power of expectoration is often lost, and mucus accumulates about the 
lower part of the pharynx, and is only dislodged by an effort of vomiting. 
The taste is always more or less blunted. In some cases a constant prick- 
ing sensation is felt in the throat. Some illustrative cases will be found 
under " Neuroses of the Larynx," and the various associated paralyses 
which occur in diphtheria are briefly described in the article on that sub- 
ject. 

1 Ziemssen's Cyclopaedia, p. 993. 2 Loc. cit. 

3 Lancet, March 4, 1871. 4 Clin. Soc. Trans., 1871. p. 92. 

5 Donders : New Sydenham Soc. Trans., 1864. 



86 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

Galvanism and faradism should be applied every day or two, by means 
of the laryngeal electrode, until a decided amelioration of the symptoms 
is obtained. At the same time general tonics are indicated, and strych- 
nia may be administered, either hypodermically or by the mouth. The 
patient should only be allowed to swallow panada, soups made almost 
solid by the addition of corn flour, and very firm wine jellies. Occa- 
sionally it may be necessary to feed with the oesophageal tube, ox per 
rectum. 

Paralysis of the palate in association with facial paralysis occurs, ac- 
cording to Erb, 1 when the cause of paralysis is situated above the geni- 
culate ganglion. The uvula usually deviates to one side or the other — 
generally to the healthy side, and scarcely moves in phonation. This 
nerve-lesion does not require any special treatment, as it is merely an un- 
important though interesting phenomenon sometimes occurring in con- 
nection with facial paralysis. 

Palato-glosso pharyngeal paralysis is always one of the most marked- 
phenomena of progressive bulbar paralysis. The disease is said to be 
rarely met with before the age of forty, but I have treated patients aged 
twenty-seven, twenty-nine, and thirty-eight. Exposure to cold is often 
the cause of the disease, but it has been likewise attributed to prolonged 
mental excitement, bodily fatigue, and insufficient nourishment. The 
malady commences in the tongue, next affects the lips, and soon after 
the palate and pharynx. There is indistinctness and slowness of speech 
at an early period of the disease from the imperfect mobility of the 
tongue, but before long the labial consonants and vowels cannot be prop- 
erly formed, and all words in which p b v f m occur, and those com- 
mencing with w y o n, are indistinctly pronounced. As the disease pro- 
gresses, speech becomes quite unintelligible, and dysphagia, which at a 
very early stage is present to a slight extent, becomes so severe that the 
patient can scarcely take an atom of food or a drop of fluid. His saliva 
cannot be swallowed, and dribbles from the mouth. The extreme dys- 
phagia is partly due to the paralysis of the constrictors and partly to pa- 
ralysis of the epiglottis, which, being unable to close over the larynx, 
permits the ingesta to enter the air-passage. The salivary secretion can- 
not be swallowed, and is at the same time absolutely increased in quan- 
tity. The patient can often only sleep sitting in a chair, with his head 
resting on the table, so that the saliva may run out of the mouth. If by 
chance, during sleep, the saliva reaches the larynx, the patient awakes 
with a fearful attack of spasm of the glottis. 

The disease consists essentially in degenerative atrophy of the gray 
nuclei in the floor of the fourth ventricle, in sclerotic changes in the me- 
dulla and spinal cord, and in atrophy of the paralyzed nerves and muscles. 

The disease is probably always fatal, the cases of supposed recovery 
from progressive bulbar paralysis having most likely been due to pressure 
on the medulla. Life is so distressing whilst it lasts, that the duty of the 
physician is to promote the euthanasia. 

Paralysis of the constrictors is characterized by dysphagia, and loss 
of power of the oesophagus always coexists. The same treatment is re- 
quired as that hereafter recommended for the oesophageal affection. 2 

1 Ziemssen's Cyclopaedia, vol. xi. p. 496. 

2 This completes the list of diseases of the pharynx proper. Those which follow- 
generally attack the pharynx in common with the mucous membrane of the adjacent 
parts. 



APHTHAE. 87 

APHTHAE. 
(Synonym: Thrush.) 

Lathi Eq. — Aphthae. 

French Eq. — Aphtheuse. Muguet. 
German Eq. — Schwammchen Aphthen. 
Italian Eq. — Afte. * 

Definition. — Inflammation of the mouth and throat characterized by 
the presence of whitish vesicles or ulcers, which frequently serve as a 
nidus for parasitic fungi. 

Etiology. — Aphthous spots are occasionally met with in the pharynx, 
though they are more common in the mouth. The affection is most fre- 
quently met with in new-born infants, and in these cases acidity of the 
stomach is almost always present; but it also occurs in the last stages of 
debilitating diseases, especially phthisis, and is occasionally met with as 
a sequela of measles. Aphthous affections are much oftener seen in cold, 
damp climates than in warm and dry regions. A low state of the system 
appears to be the most important factor in the production or predisposi- 
tion to aphtha?. According to Fabre ' the autumn season is most favor- 
able to the occurrence of the disease. 

Symptoms. — Small white spots or patches about the size of a pin's 
head are seen in the greatest number on the inside of the lower lip and 
cheeks, on the sides and under surface of the tongue, on the tonsils, and 
on the veil of the palate. Two stages can sometimes be recognized in the 
course of aphthae, viz., a vesicular and an ulcerative condition, but some- 
times there is a small patch of exudation from the commencement. The 
vesicles first appear as small elevations or papules, of a red color, hard, 
and painful. They quickly become white at their summits, and are dis- 
tended by a fluid which soon ruptures the vesicles. Small superficial 
ulcers, with steep sides and a grayish white floor result. The floor is cov- 
ered by pultaceous matter, which is constantly secreted and thrown off — 
sometimes in large quantities. When the ulcers are about to heal they 
lose their whitish aspect, and the circumference gradually narrows, until 
a livid speck on the mucous membrane is the only trace of the former 
presence of the aphthae. Sometimes the lining membrane of the mouth 
and throat looks as if it had been dusted over with flour — the whole of the 
mucous membrane being covered with minute white specks. When the 
spots and ulcers are very numerous they become confluent, and in some 
cases successive crops of vesicles continue to come out for several weeks. 
Great soreness of the mouth and fauces accompanies aphtha?, and in many 
cases a marked febrile condition of a sympathetic nature is excited by the 
malady. In the case of infants there is often diarrhoea with flatulency 
and colicky pains. 

Diagnosis. — Separate spots of aphtha? are not likely to be mistaken, 
but when the disease is confluent the appearance of a false membrane is 
simulated, and close examination will be necessary, in order to diagnose 

1 Diet, des diet, de Med. 



88 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

between this malady and diphtheria. The whitish pultaceous matter 
which breaks up on being touched can be easily distinguished from the 
homogeneous, closely adherent, and tough membrane of well marked diph- 
theria, but there are some cases which occupy a middle ground and are 
very difficult to differentiate. 

Pathology. — The nature of the affection has to a great extent been 
explained in speaking of the symptoms. It remains only to be added 
that a special fungus, the oidium albicans, is often met with in great 
quantities in the whitish cord-like matter which characterizes the disease. 

Prognosis. — In infants aphthae seldom cause death, but in rare cases 
the oesophagus may become ulcerated to such an extent as either to ren- 
der swallowing impossible or to provoke ejection of food as soon as it 
reaches the stomach. In the last stage of debilitating diseases aphthae 
generally constitute an unmistakable sign of approaching dissolution. 

Treatment. — In the case of infants it is very important to attend to 
the diet, which, if possible, should consist of the mother's milk alone. 
Lime water, or the alkaline carbonates, are often of great service. As an 
internal agent chlorate of potash appears to exert a remarkable influence 
in hastening the disappearance of the aphtha?. Five or six grains may be 
given every four hours. Pernitrate of iron may also be used advanta- 
geously as an internal remedy. A general tonic and analeptic treatment 
will always be required in addition to other measures. The Mel Boracis, 
P. B., or borax diluted with white sugar (1 in 10), is an excellent remedy 
in the case of children. A pinch of the latter mixture should be placed 
at the back of the child's tongue, and allowed to dissolve. The pain and 
soreness are usually much relieved by the frequent use of honey or glyce- 
rine, with borax. Equal parts of glycerine and turpentine are very bene- 
ficial in the later stages. The ulcers can often also be successfully treated 
by daily application of sulphate of copper (gr. x. ad J j.). In the case of 
adults where there is great soreness, free cauterization with the solid stick 
of nitrate of silver affords immediate and marked relief. Sir William 
Jenner ] first pointed out that in cases where a parasitic fungus is present 
a lotion of sulphite of soda (a drachm to the ounce) will kill the parasite, 
and thus cure the disease in about twenty-four hours. 



DIPHTHERIA. 2 

Synonyms. — Several pages might be written of synonyms which at 
different times have been employed in describing diphtheritic affections, 
but simple inflammatory diseases, distinctly pellicular affections, and le- 

1 Med. Times and Gaz., vol. vii. p. 183. 

2 Inasmuch as a diphtheria generally commences in the pharynx, and when it 
affects other parts, most frequently attacks them by extension. I have thought it 
right to treat the whole disease in this section. I am the more inclined to adopt this 
plan as I entertain the view that croup is only a form of diphtheria in which the local 
expression is found in the larynx and trachea — as it often is in the nares (with or 
without its occurrence in other parts). This proposition will be developed in the body 
of the article in some detail, and I have only to remark here that, by sacrificing the 
strictly anatomical arrangement of the work in this instance. I hope to give a better 
idea of the disease as an entity, than I could do if I treated the diphtheritic affections 
of the larynx and nose in separate sections. 



DIPHTHERIA. 89 

sions of innervation have been so confused together by the earlier writers 
in medicine, that there is little or no advantage to be gained by collect- 
ing the numerous synonyms employed by different authors at various 
times. The term diphtheritis was originally suggested by Bretonneau, 
who, observing that the disease was differentiated from other similar mal- 
adies by the formation of a false skin or membrane, coined the word 
diphtherite from the Greek SicfaOepa, a skin or parchment, and ite from m/s 
(el/ui), hasty, impetuous, the well-known termination used in medicine to 
imply inflammation. Trousseau subsequently modified the word to diph- 
therie, in order to get rid of the etiological doctrine of inflammation which 
the affix indicated, and the term diphtheria was adopted by our Registrar- 
General. Names indicative of inflammation still hold their ground, how- 
ever, amongst German and Italian writers. 



Latin Eq. — Cynanche membranacea; C. maligna; C. pharyngea maligna; 
C. pharyngea epidemica; C. trachealis. Angina suffocativa; A. 
polyposa; A. membranacea; A. perniciosa. Diphtheria. Diphthe- 
ritis. 

French Eq. — Anginecouenneuse; A. fibrineuse. Diphtherite. Diphtheric 

German Eq. — Diphtheritische Entziindung der Rachen- und Kehlkopfs- 
schleimhaut. 

Italian Eq. — Mala in canna. Difterite. 

Definition. — A specific communicable disease, occurring epidemically, 
endemically, and solitarily, 1 and characterized by more or less inflamma- 
tion of the mucous membrane of the pharynx, larynx, or air-passages, and 
by the formation on the surface of those parts — especially on the mucous 
membrane of the fauces and windpipe — of a layer or layers of lymph or 
false membrane, generallv showing- signs of bacteroid mvcosis. During 
an epidemic other mucous surfaces exposed to the air, and wounded sur- 
faces of the common integument occasionally, but less frequently, become 
covered with a layer of lymph, subsequently to, or independently of, a 
formation of membrane in the more ordinary situations. The disease is 
generally of an adynamic character, is often associated with a disturbance 
of the renal function (albuminuria), and is frequently followed by lesions 
of innervation rarely giving rise to permanent paralysis. The symptoms 
as regards respiration, vocalization, and deglutition vary with the site of 
the disease. By far the larger proportion of fatal cases terminate by 
gradual apncea, but a certain percentage sink from asthenia, blood-poison- 
ing, and cardiac thrombosis. 

History. — The presence of a membraniform deposit in the fauces seems 
to have been regarded as a morbid condition, attended with considerable 
■danger to life, from the earliest times. Hippocrates is supposed to have 
•called attention to it more than two thousand years ago, and Aretreus 
lias given a description which answers in many respects to the disease as 
now seen. But centuries before the time of Hippocrates an Indian writer 
had included in his " System of Medicine " 2 a description which is even 

1 I have used this word in preference to the term ' ' sporadic " which is commonly 
•employed in connection with diseases supposed to be of spontaneous origin, or at any 
rate is applied to those which it is presumed arise from accidental causes, indepen- 
dently of any contagious influence. 

- This systematic work on medicine is written in Sanscrit, by D'hanvantare. and 
■compiled by his pupil, Susruta. A Latin translation, by F. Hessler, was published at 



90 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

more suggestive of diphtheria. The writer mentions a disease in which 
" an increase of phlegm and blood causes a swelling in the throat, char- 
acterized by panting and pain, destroying the vital organs, and incur- 
able." 1 He also says, " a large swelling in the throat, impeding food and 
drink, and marked by violent feverish symptoms, obstructing the passage 
of the breath, arising from phlegm combined with blood, is called ' closing 
of the throat.' " 2 With these passages it may be well to contrast the 
description given by Aretaeus of the Syriac ulcer, a malady which is gene- 
rally considered to have more points of resemblance to the diphtheria of 
to-day than any other disease of antiquity. Describing ulcers on the ton- 
sils, 3 Aretaeus tells us that some are mild and harmless, while others are 
pestilential and fatal. The former — which are common — are clean, small, 
and superficial, and are unaccompanied either by pain or inflammation. 
The latter — which are rare — are extensive, deep, putrid, and covered with 
white, livid, or blackish concretion. Aretasus then goes on to describe 
the way in which, in fatal cases, the disease progresses, stating that "if 
it extends rapidly to the chest through the windpipe, the patient dies on 
the same day by suffocation." No more definite description of any dis- 
ease which we can identify with diphtheria has been given, either by the 
contemporaries or the successors of Aretaeus, and we must pass over many 
centuries before we come upon any authentic record of the prevalence of 
such a disease. 

It is not until we arrive at comparatively modern times that we find 
diphtheria forcing itself upon the attention of physicians as a distinct 
disease. Baillou, a distinguished French physician, who flourished in the 
last quarter of the sixteenth century, was the first to publish an accurate 
description. It is in his writings that we find the first definite mention 
of a false membrane. 4 A few years later, the same appearance was noted 
by several Spanish physicians as occurring in the course of an epidemic 
disease, which they minutely portrayed under the name of " garrotillo." 
The best description is that of Villa Real (1611), who states that he has- 
seen a thousand times (millies vidi) in patients, at the first onset of the 
disease, a white matter in the fauces, gullet, and throat. He adds that 
this matter is of such nature that if you stretch it with your hands it ap- 
pears elastic, and has properties like those of w T et leather — facts which he 
noticed, not only by observing the matter coughed up by the living, but 
also by the examination of it in the dead. 5 The descriptions of Fontecha 8 
(1611) and Herrera 7 (1615) are less satisfactory, as containing no account 
of post-mortem appearances; but they are valuable in so far as they con- 

Erlangen in 1844, and is in the British Museum ; it has the following- title : Susrutas 
Ayurvedas ; id est Medicinse Systema a Venerabili D'hanvantare Demonstration a S. 
DiLcipulo Compositum. It is from this translation that the quotations in the text are 
taken. 

1 Ibid. p. 202. 

2 Ibid. p. 205. The following passage may also possibly describe diphtheria : — u Si 
quis valde lugens semper suspirat, interruptam vocem, et aridum solutumque sonum 
habet in respirationis viis, phlegm ate oblitis, hie morbus propter suspirium vocis oc- 
cisor cognoscendus est." — Ibid. 206. 

3 Aretgeus : De Causis et Signis Acutorum Morborum, lib. i. cap. 9. 

4 Gulielmi Ballouii : Epidemiorum et Ephemeridum, libri ii., Parisiis, 1G40, p. 201.— 
" Pituita lent a contumax quag instar membrange cujusdam arteriae asperae erat obtenta." 

5 Johannis de Villa Real : De Signis, Causis, Essentia, Prognostico et Curatione 
Morbi Suffocantis. Compluti, 1611, p. 35 et seq. 

6 Disputationes Medicse, etc., opus Doctoris Fontecha, Compluti, 1611. 

7 De Essentia, Causis, Notis, Praesagio, Curatione et Prsecautione Morbi Suffocantis 
Garrotillo Hispane Appellati, auctore Doctore Herrera, Matriti, 1615. 



DIPHTHERIA. 91 

firm the fact of the prevalence of garrotillo in Spain between the years 
1581 and 1611. Some years subsequently to the latter date diphtheria 
appears to have prevailed as a fatal epidemic in Naples and other parts of 
Italy. Sgambatus ' tells us that in 1617 a highly contagious affection of 
the throat appeared, attacking the children of rich and poor alike, and 
often sweeping away whole families. The same epidemic is described by 
Nola'and Carnevale, 3 the latter of whom asserts that it was identical 
with that which had been prevailing in Spain, under the popular name of 
"garrotillo." The writings of Cortesius 4 (1625) render it nearly certain 
that the same disease extended somewhat later to Sicily. A membrane 
in the throat, which could be readily torn away, is distinctly described 
as being one of its symptoms. The works of Alaymus 5 (1032) and of 
Aetius Cletius 6 (1636) have also been quoted as affording corroboratory 
evidence of the prevalence of diphtheria in Italy and Sicily during the 
seventeenth century. Medical literature is then silent on the subject for 
nearly a century, but after that time follows a rapid series of observa- 
tions from different parts of Europe. In 1713 Dr. Patrick Blair, 7 in a 
letter to Dr. Mead, described a disease as " the croops," which he says. 
" was epidemic and universal " at Coupar Angus, and which was no doubt 
diphtheria. In 17-48 Ghisi 8 observed an epidemic of the disease in Paler- 
mo; in 1740 Marteau de Grandvilliers 9 described a similar outbreak in 
Paris; in 1750 the formation of a membraniform concretion in the throat 
is distinctly described by Dr. John Starr, 10 as occurring in an epidemic 
in Cornwall, and in 1757 a similar observation was made by "Wilcke ll in 
Sweden. In the same year, Dr. Huxham 12 described an epidemic which 
had been prevalent at Plymouth, in which some of the cases were exam- 
ples of scarlatina anginosa, whilst others were undoubtedly cases of sec- 
ondary diphtheria. 

x\t length the attention of the profession was fully called to the pecu- 
liar characters of diphtheria by Dr. Francis Home, 13 of Edinburgh, who, 
in 1765, under the name of croup described an acute affection of the 
larynx and trachea, coming on insidiously, attended with the formation 
of a membrane in the pharynx and air-passages, and often causing death 



I De Pestilente Fauciura Affectu, Neapoli Sasviente Opusculura, auctore Andrea 
Sgambato, Neapoli. 1620. 

■ De Epidemico Phlegmone Anginoso Grassante Neapoli, Franciscus Nola, Venetiis, 
1620. 

3 De Epidemico Strangulator io Affectu in Neapolitam urbem Grassanti et per regna 
Neapolis et Sicilise Vagante, auctor Jo Baptista Carnevale, Neapoli, 1620. 

4 Johannis Baptistse Cortesii : Miscellaneorum Medicinse Decades Denae, Messanae, 
1625. 

6 Marci Antonii Alaymi : Consultatio pro Ulceris Syriaci nunc Vagantis Curatione, 
Panhormi, 1632. 

6 De Morbo Strangulators, opus Aetii Cletii Siguini, Roma, 1636. 
: Observations in the Practice of Physic, etc., London, 1718. 
e Lettere Mediche del Dottore Martino Ghisi, Cremona, 1749. 

9 Dissertation Historique sur Tespece de Mai de Gorge Gangreneux qui a regne par- 
mi les Enfants Tannee derniere, Paris, 1749. 

10 Philosophical Transactions, 1752, vol. xlvi. p. 485. 

II Dissertatio Medica de Angina Infantum in Patria Recentioribus annis Observata,. 
Wilcke, Upsalae, 1764. 

'-' A Dissertation on the Malignant Ulcerous Sore Throat, 1757, though generally 
quoted by writers on diphtheria, is not referred to above, as it really deals with scar- 
latina anginosa. 

13 An Inquiry into the Nature, Cause, and Cure of Croup, by Francis Home, M.D.,. 
Edinburgh, 1765. 



92 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

by suffocation. Home appears to have been the first to notice the quick, 
weak pulse which is so characteristic of the disease. The treatise of the 
Scotch physician attracted the attention of Dr. Michaelis, 1 of Gottingen, 
who, in an essay published in 1778, confirms and supplements his obser- 
vations. From time to time epidemics of scarlatina were described in 
which the throat symptoms predominated, and some of these have been 
wrongly supposed to have been examples of diphtheria. 3 The next record 
of the disease comes from America, where in 1789 Dr. Samuel Bard, 3 of 
Philadelphia, published a minute account of " an uncommon and highly 
dangerous distemper " which had recently proved fatal to many children 
in New York. Dr. Bard was a careful and painstaking observer, and his 
monograph contributed very considerably to the accuracy of contempo- 
rary knowledge with regard to diphtheria. In 1798* another American 
physician, Dr. John Archer, published an interesting paper, and recom- 
mended a new remedy for the disease. In the year 1801 Dr. Cheyne, 6 
a British physician, published an essay in which he distinctly portrays 
diphtheria under the name of cynanche trachealis or croup. He recog- 
nizes it as the same disease as that referred to by Ballou, Ghisi, Home, 
and Michaelis, and gives a minute description and plates of the false mem- 
brane found in the trachea after death. In 1802 Dr. Cullen, 6 the well- 
known professor of the practice of physic in the University of Edinburgh, 
gave a description of cynanche trachealis, in which we cannot fail to rec- 
ognize the diphtheria of modern times. For many years after its appear- 
ance Dr. Cullen's work was the favorite text-book on medicine with all 
British practitioners and students, and its author, therefore, may claim 
the credit of having rescued diphtheria from the region of discussion and 
monographs, and of having given it a fixed and recognized position in 
medical science. The disease, however, was evidently still a rarity in the 
British Isles, and it probably only occurred in the isolated form. Tn 
France the case was otherwise: the disease was well known as a frequent 
visitor, under the name of croup, and having caused the death of some of 
the members of the Imperial family in 1807, a prize was offered by Napo- 
leon I. for the best essay on the subject. This led to the publication of 
the valuable works of Albers, Jurine, and Royer-Collard — works which 
were worthy predecessors of the classical memoirs of Bretonneau. 7 The 
latter owed their origin to an alarming outbreak of the disease at Tours in 
the latter part of the year 1818. The epidemic was most carefully investi- 
gated by Bretonneau, who published an account of his researches in 1826. 
An accurate description of " diphtherite " was given by Dr. Abercrombie 
in a work published in 1828. 8 The disease appears to have prevailed in 
an epidemic form in Edinburgh in the year 1826, but otherwise it was by 

1 De Angina Polyposa sive Membranacea, Gottingen, 1778. 

2 An Account of the Sore Throat attended with Ulcers, by Dr. John Fothergill. 
London : Fifth edition, 1769. 

3 Transactions of the American Philosophical Society, Philadelphia, 1789. 

4 An Inaugural Dissertation on Cynanche Trachealis, commonly called Croup or 
Hives, Philadelphia, 1798. 

5 Essays on the Diseases of Children, with Cases and Dissections, by John Cheyne, 
M.D., Edinburgh, 1801. 

6 First Lines of the Practice of Physic, by William Cullen, M.D., Edinburgh, 1802, 
vol. i., p. 219. 

' Des Inflammations Speciales du Tissu Muqueux et en particulier de la Diphthe- 
xite, Paris, 1826. 

s Pathological and Practical Researches on the Diseases of the Stomach, etc., by 
John Abercrombie, M.D., Edinburgh, 1828. 



DIPHTHERIA. 93 

no means a common affection in this country. In fact, after the brief 
notoriety conferred on diphtheria by the works of Bretonneau, the disease 
seems to have passed from the minds of English physicians, and its very 
existence to have been almost forgotten. It still occurred from time to 
time in all parts of Europe, but it did not excite attention to any great 
extent until the year 1853, when it broke out with some violence in Paris. 
In 1855 an epidemic at Boulogne, which was especially fatal to the resi- 
dent English, excited considerable attention, and during the two follow- 
ing years serious outbreaks were reported from different parts of France. 
The first case of the greatest epidemic of the disease which, as far as is 
known, has ever occurred in this country, was imported from Boulogne 
to Folkestone in 1856, 1 but it was not till 1858 that the disease attained 
very alarming proportions in this country. Spreading, as it seemed, from 
many independent centres, it raged as a widespread and fatal epidemic 
during 1859, and continued very seriously prevalent during the three fol- 
lowing years. 2 Since that time diphtheria has not appeared in England 
with anything like the same malignancy; it still claims several thousand 
victims annually, but its invasions are for the most part circumscribed in 
area, and both in this country, and on the Continent, only expand from 
time to time into limited epidemics. 

Etiology. — The exciting cause is a specific contagium, and those cases 
which appear to originate de novo, probably always arise from the virus 
— often long dormant and forgotten — of previous cases. Tender age is 
the principal predisposing cause, but the accidental existence of pharyn- 
geal catarrh, or of any disease which lowers the system, probably increases 
individual receptivity. Family constitution also often exercises an unfav- 
orable influence. 

The natural history of the contagium has not yet been elucidated. 
Some information has been obtained as to the atmospheric conditions and 
temperature under which the poison exists and flourishes, but considerable 
uncertainty exists as to the laws which govern its development and effect 
its diffusion. The mode or modes also in which the disease producing 
virus enters the system, and its period of incubation, have not yet been 
accurately determined. These various points will now be considered in 
detail. 

The Natural History of the Contagium. — The contagious principle has 
not been isolated, although it is highly probable that it consists of mi- 
nute particles of matter, which are capable of floating in the atmosphere, 
and attaching themselves to rough surfaces [see Mode of Diffusion). The 
doctrine has been put forth by Oertel, Hueter, Nassiloff, and Letzerich, 
that a minute fungus is the essential contagium. The views of these 
authors will be referred to in detail in treating of the pathology, and it is 
sufficient to state here that the observations are not sufficiently conclu- 
sive to warrant us in considering that the essence of the disease has yet 
been discovered. Low vegetable organisms probably play an important 
part in the propagation of the disease, but the exact relation between 
the disease and the organisms has not as yet been made out. The ex- 
periments of Oertel, Letzerich, and others, if uncontradicted, would only 

1 Reports of the Medical Officer of the Privy Council, No. ii., Loudon, 1860. 

' J The best accounts of the epidemics of that period are those of Mr. Ernest Hart : 
Diphtheria, London, 1859, and Mr. Netten Radcliffe : The Recent Epidemic of Diph- 
theria, Trans, of the Epidem. Soc, February, 1802. 



94 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

show that micrococci are an invariable concomitant of diphtheria; that 
they are the sole or even the main agent in its causation cannot as yet be 
considered proved. Dr. Maclagan ' has, however, clearly shown that " the 
germ theory" explains all the phenomena of the specific fevers, and in a 
matter, which at present is beyond inductive proof, analogy is of the 
highest value. For a further consideration of this subject, the reader is 
referred to the section on Pathology. 

In considering the etiology of the disease, it is most important to de- 
termine whether it can originate de novo or not. Although the disease 
so often arises in connection with bad drainage, foul habits, and impure 
water supply; and although it is so often impossible to trace the remotest 
channel of contagion, yet the whole tendency of sanitary science is op- 
posed to the doctrine of the spontaneous origin of specific diseases. 2 It 
must not be forgotten that in those cases where the disease appears to 
enter the system through the use of drinking water contaminated with 
excrementitious matter, the specific germs of the disease, derived from 
persons previously suffering from it, may have found their way into the 
water. I have frequently known the disease occur suddenly in remote 
country districts, where careful inquiries have failed to discover the 
smallest evidence of infection, but similar phenomena are often observed 
in connection with scarlatina and small-pox — diseases which no one would 
now attribute to a spontaneous origin. 3 A very remarkable instance of 
the apparently spontaneous origin of the disease was observed last year 
by Dr. Semon, at a small health resort, called " Bad Fusch " in the Tyrol. 
The place, consisting of only two houses, is situated at an elevation of 
from 3,000 to 4,000 feet above the sea, and is celebrated for its fresh air 
and pure water. In one of these houses a little girl, five years of age, 
who had left Vienna five weeks previously, was suddenly attacked with 
diphtheria, which was subsequently followed by paralysis. The visitors 
consisted almost entirely of tourists, ascending the high mountains in the 
neighborhood. Although other children had been playing with the lit- 
tle girl up to the day on which she was attacked, no other case of this 
kind occurred. It need scarcely be said that the outbreak of the dis- 
ease in this case may, however, also be explained in accordance with the 
theory of contagion. 

Climatic and Atmospheric Conditions under which the Contagium 
Lives and Flourishes. — The disease exists in almost every country, but 
it is most common in temperate climates. The contagium lives under 
ordinary atmospheric conditions, but it is probable that dampness favors 
its development. It occurs in the tropics, but does not appear to have 
been noticed in the Arctic regions. It seems likely that the germs may 
remain dormant, external to the body, for a considerable period, and may 
only develop under the stimulus of some particular atmospheric condi- 
tions, 4 or when a suitable nidus presents itself. In making statistical in- 
quiries, with reference to the registration of disease in sub-districts, Dr. 
Thursfield 5 found in certain isolated hamlets and houses where in recent 

1 The Germ Theory, etc., London, 1876. 

2 Simon : Sixth Report on Public Health, quoted by Dr. Aitken : The Science 
and Practice of Medicine. Sixth edition, vol. i. p. 338. 

3 Dr. Kelly also states, as the result of his experience as the sanitary officer of a 
wide tract of country, that diphtheria often appears in lonely outlying places, far away 
from any main road ; and often no history of contagion can be traced at all. — Second 
Annual Report of the Combined Sanitary Diatricts of West Sussex. 

4 Sanne : Traite de la Diphtherie, Paris, 1876, p. 231. 
6 Lancet, vol. ii. 1878, Nos. vi. vii. viii. 



DIPHTHERIA. 95 

years he had been called upon to investigate cases of diphtheria, that at 
intervals of five, ten, fifteen, twenty-five, thirty, and even more years, 
there had been previous outbreaks of fatal sore throat. An instance is 
recorded by Dr. William Squire l in which the virus remained latent 
•eleven months, and then led to the development of the disease when a 
person occupied the room in which a case of diphtheria had previously oc- 
curred. I have known the poison to remain dormant for four, seven, and 
fifteen months, and in one instance for three years, and then again to be- 
come active. From the above considerations the vitality of the disease- 
germs would seem to be considerable. 

In Great Britain the disease has generally been prevalent in those 
parts of the country where the rainfall is great, in villages situated in 
valleys, or in places where there is not sufficient fall to get rid of the sur- 
face drainage, but it has also been frequently met with, and shown great 
•epidemic persistency, in high, dry, and exposed situations. 

The disease is much more common in rural than in urban districts. 
"Whether, however, this fact points to the greater humidity which pre- 
vails in the country, or to the absence of proper drainage, is not at pres- 
ent certain. According to Dr. Thursfield, 2 whose experience as a sanitary 
inspector extends over twelve hundred square miles, " with a population 
of rather more than two hundred thousand, of which rather more than one 
hundred thousand are rural, the number of fatal cases of diphtheria in the 
rural portion is nearly three times that in the urban portion." The same 
author remarks that whatever conditions seem to promote fungoid growth, 
would appear to favor the incidence and persistence of the disease, and 
the explanation of the comparative immunity of towns may be the pres- 
ence of something in their atmosphere inimical to such growth. 

Until recently the extension of the disease was considered to be in- 
dependent of season, but the observations of Wibmer 3 and Thursfield 4 
tend to show that it prevails more extensively during the winter months 
than at other periods of the year. Many severe epidemics have, how- 
ever, steadily raged through the whole round of the year in spite of the 
most varied changes of weather and temperature. 

Mode of Diffusion. — Considerable difference of opinion exists as to 
the mode in which the poison is diffused. The disease may be imparted 
to others by a person actually, or lately, suffering from it, but the ex- 
treme difficulty of effecting artificial implantation would tend to show 
that direct contagion is rare. From this fact it would seem probable that 
the contagium, when set free from the affected individual, undergoes fur- 
ther development (as in the case of cholera and typhoid fever), which 
increases its disease-producing properties. It is asserted that the poison 
may be conveyed by a person not actually affected by the disease. Dr. 
Thursfield 5 has reported a very remarkable case, in which a woman living 
in an infected house, but not at any time suffering herself, walked a mile 
or two and crossed a ferry to visit a friend. She only remained a short 
time in the house, but sufficiently long to leave the germ of diphtheria, 
which broke out a day or two afterward. This, however, is such an ex- 
ceptional example, that the possibility of the malady having arisen from 



1 Reynolds' System of Medicine, vol. i. p. 379. - Loc. cit. 

9 Statistischer Bericht iiber die Munchener Epidemien, 18G4 — 69, quoted by Oertel: 
-Ziemssen s Cyclopaedia, vol. i. p. 590; also Deutsch. Arch. f. kl. Med., 1870, vol. viii. p. 
242 ; Experimented Untersuchungen iiber Diphtheritis, p. 346. 

4 Loc. cit. b Loc. cit. 



96 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

other sources must be borne in mind. In one instance I have known the 
disease caught from a patient who had entirely recovered from it four 
months previously, but whether it was conveyed by the person or the 
clothes of the individual, it was impossible to determine. In solitary 
cases the contagium does not usually assume a virulent form, and proper 
measures are almost invariably successful in confining the disease to a 
limited area. The distance at which the contagious principle can operate 
as a rule appears to be more limited than is the case in typhus or small- 
pox. Thus I have known an instance in which seven children were af- 
fected in a house which had a residence on each side of it, and a third op- 
posite at a distance of only twenty-four feet. Although in all these 
buildings there were young children, no other case of diphtheria occurred. 
Other similar illustrations of this fact are on record. 1 Under certain cir- 
cumstances, however, the diffusive powers are increased, and, as appears 
to be the case in epidemics of influenza, the poison may be wafted over 
extensive tracts of country. 

The germs of diphtheria appear to have an affinity for the walls of 
rooms, and, according to some observers, may attach themselves to clothes 
and articles of furniture. 2 It is probable that by the introduction of such 
things the poison is often diffused. 

Manner in which Poison enters the System. — The poison may be re- 
ceived into the system (a) by direct implantation; (b) through the circum- 
ambient air; (e) through the water that is drunk, or the food that is eaten. 
Further, it is possible that it may be occasionally introduced by inocula- 
tion, either with portions of false membrane or with the blood of a patient 
suffering from the disease. 

(a) The melancholy deaths of Valleix and Henri Blache, 8 show that 
the disease may occasionally originate from direct implantation. M. See 4 
has reported a case of the same character, in which a woman suckled a 
child affected with diphtheria. In consequence her own child, which she 
was nursing at the same time, contracted labial diphtheria, and communi- 
cated it to the mother, who frequently kissed her infant. An instance of 
direct implantation has been placed on record by Professor Bossi, 6 in 
which a greyhound was seized with symptoms akin to those of diphtheria 
four days after swallowing the excrement of a child who died of that dis- 
ease; after death a membranous exudation was found on the animal'& 
fauces. 6 

(b) The contagium which exists in the secretions and exhalations of 
the sick may pass into the air and find its way directly into the healthy 
organism by absorption through the lungs, or through the mucous mem- 
brane of the throat; or the secretions of the sick may pass into drains, 
and sewer-gas, holding the disease germs in suspension, may be afterward- 
inspired. 



1 Thursfield : Loc. cit. 2 Sanne : Op. cit. 

3 Trousseau : Clin. Lectures, New Syd. Soc. Trans., vol. ii. p. 497. 

4 Bull, de la Soc. Med. des Hop. , t. iv. p. 378. 

5 Sir J. R. Cormack : Clinical Studies, vol. ii. p. 273 ; Lo Sperimentale, 1872, p. 
230. 

6 Dr. Sanderson has placed on record a somewhat analogous illustration : Three 
sows, which had access to a piece of waste ground on which " the discharges or concre- 
tions" of some patients suffering from diphtheria were thrown, quickly died with 
symptoms of suffocation, enlarged submaxillary glands, and in one case with diphther- 
itic membrane in the fauces. — Reports of the Medical Officer to the Privy Council, Lon- 
don, 1860. 



DIPHTHERIA. 97 

(c) The poison may be conveyed through food or water (or other fluid 
used for drinking purposes), as in the analogous case of typhoid fever. 
Here it may be mentioned that Bossi's case, referred to above, may be an 
example of the manner in which the poison is absorbed through the ali- 
mentary canal — not an example of direct implantation. In many of the 
cases of diphtheria which I have seen during the last few years, the 
drinking water was found to be contaminated with excrementitious matter. 

As regards direct inoculation with diphtheritic membrane, the experi- 
ments made with false membrane, by Trousseau, 1 Peter, and Duchamp,* 
upon themselves, and by Dr. G. Harley 3 upon animals, gave only nega- 
tive results. In the experiments of Trendelenburg * and Oertel, 5 on rab- 
bits, a diphtheritic membrane formed in the trachea, as the result of direct 
irritation of that part with diphtheritic matter, and the animals died on 
the second or third day, with acute kidney disease, and symptoms of gen- 
eral infection. Nassiloff 6 and Eberth 7 have produced diphtheritic kera- 
titis by direct inoculation, while Hueter and Tommasi 8 and Oertel, in their 
experiments on the muscles, found that soon after inoculation a diphthe- 
ritic layer appeared round the edges of the wound; hemorrhagic inflam- 
mation was induced in the muscles, and the animals died on the second day 
from general blood-poisoning. Although in some of these experiments a 
false membrane was produced, the septicaemia may have been merely the 
result of inoculation with decomposing animal matter, and it cannot be 
considered that true diphtheria with its specific manifestations has yet been 
artificially produced by inoculation of the lower animals, though certain 
local phenomena of great interest and importance have been induced. 

A few cases are on record in which medical practitioners are said to 
have been inoculated with blood, i. e., to have become infected through the 
accidental prick of a lancet smeared with the blood of a patient suffering 
from diphtheria, but as it is extremely difficult to inoculate successfully 
with blood in other diseases of much higher contagious power, it is highly 
improbable that diphtheria can originate in this way. 9 Moreover, it must 
not be forgotten that in the cases referred to the medical men attacked 
were exposed to the general influence of the contagion. 

Period of Incubation. — The period of incubation is exceedingly short 
— generally two or three days — but on the other hand the germs of the 
disease may remain about the person subsequently attacked for some 
weeks before the complaint makes its appearance. In illustration of the 
first-named fact, the following case, which came under my own observa- 
tion, may be cited. A girl, aged six, who had been absent from home for 
five weeks, returned one afternoon at four o'clock. Her young brother, 
aged four, had shown symptoms of sore throat the same morning, but no 
suspicion was entertained that the disease was diphtheritic. These two 
children remained together till bedtime, but did not sleep in the same 
room. The next morning both of them had marked diphtheria, with an 
abundance of false membrane. The little girl had not been subjected to 
any infection before reaching her home. On the other hand, I have 

1 Reports of the Medical Officer to the Privy Council, London, 18G0, p. 335. 

2 Du role des parasites dans la diphtherie : These de Paris. 

8 Pathological Transactions, vol. x. p. 315. 

4 Arch, fur Klin. Chirurgie, 1860, x. 2. 6 Loc. cit. 

' Virchow's Archiv, 1870. p. 550. 7 Correspondenzblatt, 1872. 

e Central blatt f. Med. Wissenschaften, 1868, p. 34. 

9 Dr. Klein : Experimental Contribution to the Etiology of Infectious Diseases : 
Quarterly Journal of Microscop. Sc, vol. xviii. p. 169 et seq. 

7 



98 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

known one instance in which the disease occurred fifteen days after ex- 
posure to contagion: A young lady, aged eighteen, insisted, contrary to 
the advice of her friends, in paying a visit to her cousins living in London, 
who were convalescent from diphtheria. She spent about two hours in 
their society, and then returned to her home in the country. Fifteen 
days after her visit she was attacked with diphtheria. 

Predisjionents. — The most obvious predisposing cause is age. From 
an analysis ' of nearly 70,000 fatal cases contained in the returns of the 
Registrar-General, it appears that in every thousand fatal cases the age at 
death is as follows: — 

Under 1 year 90 

From 1 to 5 years 450 

" 5 to 10 " : 2G0 

1 " 10 to 15 " 90 

" 15 to 25 " 50 

" 25 to 45 " 35 

" 45 years and upward 25 

Again, in the Florentine epidemic, 3 out of 1,546 cases occurring in 
the years 1872 and 1873, in only fifteen were the patients over thirty 
years of age. These figures are markedly different from any which could 
be compiled of other zymotic diseases. Sex does not influence the inci- 
dence of the disease to any appreciable extent; for, although, according 
to the Registrar-General's returns, the mortality of females from diph- 
theria is rather higher than that of males, the reverse applies to " croup," 
a term under which a very large proportion of the cases of diphtheria are 
returned. Next in importance to age as a predisposing cause would seem 
to come family susceptibility. 3 The liability of diphtheria to attack the 
members of certain families is well proved. Sir William Jenner 4 lays 
great stress upon family constitution as being " one of the most impor- 
tant elements favoring the development of the disease and determining 
its progress." He quotes one case in which five members of a family 
took the disease, two in which four, and eight in which two were affected. 
In the Florentine epidemic, in four cases diphtheria proved fatal to three 
members, and in twenty-two cases to two members of the same family. 
Some remarkable instances of family susceptibility have come under my 
own notice. In one case a poor woman had three children of her own, 
and took care of two others in no way related to herself; her own children 
were attacked by the disease, and one of them died. The other two 
children — not her own, who were constantly in the same room with the 
little patients, never suffered from the disease. In another case four 

1 Thursfield : Loc. cit. 

2 Dr. Borgiotti, Capo medico del Uffizo d'Igiene e Beneficenza, in the Rendiconto 
amministrativo della Giunta al Consiglio Communale di Forenze, collected a series 
of the most valuable statistics on the Florentine epidemic of 1871-73, but unfortunately 
they are buried in the Municipal Archives. I am indebted to Dr. Wilson, of Florence, 
for most kindly copying Borgiottf s figures from the source referred to. Dr. Borgiottfs 
views are, however, given with considerable detail in the Atti dell' Accademia, Medico- 
fisica Fiorentina, 1871-72-73. 

3 Two very painful examples of intense family susceptibility have been recently re- 
ported ; in one case eight, and in another case six children in one family were cut off 
by the disease within a few days. See Lancet, 1877, vol. i. p. 919, and Return of the 
Registrar- General of Ireland for the last Quarter of 1876. 

4 Diphtheria, its Symptoms and Treatment, London, 1861, p. 51. 



DIPHTHERIA. 99 

families occupied a house near Woodford, in Essex. In all of them there 
were several children. Two of the families were related, the mothers 
being sisters. All the children who were related to each other had 
diphtheria severely, whilst the children of the other two families escaped 
entirely. During the progress of the disease no attempt at isolation was 
made, the healthy children frequently entering the rooms of the patients. 

Social position is not without influence on the distribution of the dis- 
ease. In its endemic form it rarely attacks those who live in healthy and 
well-ventilated houses. But where it is epidemic, it manifests no respect 
for social rank or wealthy surroundings. Under these circumstances, as 
Dr. Greenhow remarks, " station of life and the enjoyment of affluence, or 
exposure to the privations of poverty seem to have but small influence 
either in predisposing persons to take or to suffer severely from the dis- 
ease." ' The statistics of Dr. Borgiotti 2 tend to show that during an 
epidemic of diphtheria no importance is to be attached to the hygienic 
condition of a locality as a cause of the malady. In the Florentine epi- 
demic many persons fell victims who lived in lofty, well-ventilated, and, 
in all respects, salubrious habitations. It must not be forgotten, more- 
over, that when diphtheria becomes epidemic in a town, an elaborate sys- 
tem of drainage is calculated to convey the poison by means of the sewers, 
and that water-closets afford a ready means of contaminating cisterns and 
introducing sewage gas into residences. Hence, the wealthy are some- 
times subjected to causes of infection which the poorest may escape. 

When an epidemic exists, the accidental occurrence of a catarrh often 
seems to attract the specific virus to the throat. 

Certain acute diseases, as well as those of a chronic character accom- 
panied with great debility, predispose to the disease, and when it attacks 
persons who have been previously suffering from some other affection it is 
called secondary diphtherial It is most apt to occur in measles and 
malignant scarlet fever, but it is met with in certain epidemics of small- 
pox, typhoid fever, and whooping-cough. It also, by no means unfre- 
quently, attacks patients in the last stage of phthisis. The disease does 
not differ essentially in its character, whether it is primary or secondary, 
but it is thought by some physicians to be less contagious under the latter 
circumstances, and it attacks adults in relatively larger numbers. 

Much still remains to be explained with regard to the etiology of 
diphtheria. No satisfactory theory has yet been offered as to the reason 
why in certain years the disease should spring up in epidemic form and 
resist all our attempts to arrest it, while at other times it arises, perhaps, 
in some remote hamlet, without any traceable antecedent, and, after 
■flickering for a time, dies away as suddenly as it appeared. 

Protective Influence of an Attack of Diphtheria. — As in the cases of 
typhoid fever and cholera, an attack of the disease probably affords a pro- 
tection — though a very slight one — against recurrence. In estimating 
the protective power exercised by an attack of diphtheria, it must not be 
forgotten that even in diseases such as small-pox and scarlatina, where 
previous attacks afford great subsequent immunity, recurrence does some- 
times take place, and that there are many well-established cases on record 
of these affections occurring more than once in the same individual. The 
fact that diphtheria recurs, in some rare instances, does not, therefore, by 

1 On Diphtheria. London, 1860, p. 134. » Loc. c:t. 

3 A description of the disease as a secondary phenomenon will be found in the suc- 
ceeding articles. 



100 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

any means disprove its protective influence in the majority of cases. I 
have myself known three instances in which children have died from the 
second attack. In two of these, the first attack (occurring a year pre- 
viously in one case, and seven months in the other) was seen by another 
practitioner; but, from the circumstances of there having been slight 
paralysis in each instance, I have no doubt as regards the diagnosis. In 
my own case, I saw a child aged four with pharyngeal diphtheria, in May, 
1874, who died of laryngeal diphtheria under my care in July, 1875. I 
have seen the disease occur, in a mild form, three times in the same indi- 
vidual, at intervals of five months, a year, and two years. 

Symptoms. — The symptoms of diphtheria vary in different cases from 
those of quite a slight sore throat to those of the most serious and ma- 
lignant blood-poisoning. Between these two extremes we meet with' 
every gradation of intensity. The presence of " false membrane " in the 
throat is the characteristic symptom, but sometimes, in slight cases, the 
disease passes off without the formation of any membranous exudation, 
and occasionally the patient dies before it is developed. Again, the local 
affection is, in some cases, accompanied with considerable inflammation, 
whilst in others there is scarcely any hyperemia. Hence it is convenient, 
in describing the symptoms, to classify the varieties of the disease. The 
following are the different constitutional forms: (1) The typical form; 
(2) the mild, or catarrhal form; (3) the inflammatory form; (4) the 
"malignant form; (5) the gangrenous form; (6) the chronic form. An 
attempt has been made to establish another variety — the insidious form; 
but whilst one author l finds its expression in the sudden development of 
laryngeal symptoms, another 2 considers that the patient either dies 
" from the progress of marasmus," " or suddenly from an effort," or 
quickly succumbs to one of the unfavorable complications which super- 
vene. It will be seen, therefore, that the insidious character cannot be 
regarded as constituting a special form of the disease. 

The student must not expect to find the first three forms always 
clearly defined; on the contrary, they are apt to run into one another, or 
their special features may be more or less combined. The differences 
dependent on site are — {a), nasal diphtheria; and (b), laryngeal diphthe- 
ria or croup. It would be foreign to the scope of this work to enter into 
the subject of cutaneous diphtheria, or to consider the local manifestations 
of the affection, when it attacks any of the various organs whose mucous 
covering is susceptible to the poison. 

The course of (1) typical diphtheria is somewhat as follows: After a 
period of incubation varying from two to five days, during which the 
patient suffers from general malaise and depression, with occasional 
chilliness, the disease announces itself by a definite constitutional disturb- 
ance. 

The first stage commences with a rapid rise in the temperature and 
pulse-rate — the former often reaching 103° and occasionally 10-4° F. 
within a few hours — an increased feeling of chilliness, loss of appetite, 
nausea, and in some instances vomiting or diarrhoea. If the patient is an 
adult he complains of pain in the loins, of headache, and often of giddi- 
ness. His attention is, however, soon diverted from these general symp- 
toms to his throat, which in a very short time begins to feel hot and dry, 
and to cause pain in swallowing, whilst the neck feels stiff, swollen, and 
tender. In a child these subjective symptoms are to a great extent lost. 

1 Jenner : Loc. cit. p. 20. 2 Sanne : Loc. cit. p. 123. 



DIPHTHERIA. 101 

The physician, called to a case such as is here described, will at once pro- 
ceed to inspect the patient's throat, and will probably find the tonsils, the 
pillars of the fauces, the uvula, and the back of the pharynx red. swollen, 
and turgid. But the false membranes which are characteristic of the dis- 
ease will very possibly have not yet made their appearance. If they have 
not, a few hours will probably suffice to develop them. 

The second- stage will then be present. On carefully watching the 
progress of the case a viscid yellowish secretion will be seen gradually 
accumulating in the depressions on one or both tonsils; a little later the 
superficial layers of mucous membrane become infiltrated at certain points 
with a yellow substance, which faises them above the level of the sur- 
rounding normal tissue. The infiltrated patches, which are at first more 
or less translucent, soon become opaque, at the same time changing in 
color from yellow to a grayish white, extending at their periphery, and 
coalescing with similar adjacent patches. In this way a considerable sur- 
face of the fauces and pharynx becomes coated with false membrane, 
which, being constantly reinforced by additions to its under surface, 
gradually assumes a leathery consistence and a lardaceous appearance. 
Strips of this membrane may now be torn off, and in some cases with care 
the whole of it may be removed in the form of a cast of the parts on 
which it is deposited. The mucous membrane beneath will be found 
robbed of its epithelium, of a vivid red color, and covered with numerous 
hemorrhagic points. Externally the neck is more or less swollen and 
brawny, whilst the parotid, submaxillary, and lymphatic glands are fre- 
quently enlarged, hard, and tender. 

The temperature in most cases gradually subsides as the exudation 
extends, but sometimes it remains at a high point, and may even increase 
as the local process develops. According to Faralli, 1 however, who made a 
series of careful observations on the temperature in sixty cases of diphthe- 
ria in the Florentine epidemic, it usually falls to normal by the fourth or 
fifth day, though in moderately severe cases it again shows a tendency to 
rise after that date. 

The patient still complains of difficulty in deglutition, and suffers from 
a constant " hawking," caused bv his endeavors to get rid of the tena- 
cious secretion which is poured out from the mucous membrane. Unless 
the mouth is repeatedly washed out with a disinfectant gargle the breath 
becomes horribly offensive, from the decomposition of the morbid secre- 
tions in the throat. The primary blood-poisoning is shown by the ex- 
treme debility, the pulse being weak and compressible, and often either 
exceptionally rapid or exceptionally slow, while the first sound of the 
heart is muffled, and devoid of tone; and by the albuminuria, which is an 
almost constant symptom in this class of cases, and appears at a very early 
period of the disease. The urine itself is scanty and high-colored, con- 
taining an excess of urea, and numerous hyaline, granular, and epithelial 
casts. 

It is at this period that the diphtheritic process, instead of limiting it- 
self to the pharynx, may spread in a downward direction, and attack the 
larynx and trachea, thus exposing the patient to the serious risk of death 
from asphyxia. This extension, when it occurs, usually takes place with- 
in three or four days of the invasion of the disease, and is in most cases 
announced by unmistakable signs. The voice becomes hoarse and muf- 
fled, the breathing is more or less stridulous, and there is a constant dry 

1 Sul ciclo termico della difterite : Iroparziale, Marzo, 1873. 



102 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

and toneless cough. To these symptoms succeed those of embarrassed 
respiration, viz., distressing dyspnoea, gradually increasing cyanosis, swell- 
ing of the face, and drowsiness, passing into fatal coma. We have, in 
fact, a case of laryngeal diphtheria or true croup — one of the most fatal 
diseases to which humanity is liable. This important subject will be 
found treated in detail further on. 

The other extensions are less important, but are of unfavorable signi- 
fication. The implication of the nasal cavity generally announces itself 
by the discharge of a fetid, dark-colored watery fluid, which excoriates 
the margins of the nostrils. This condition may remain until the patient 
recovers or dies, or it may be followed by the formation of false mem- 
brane on the lining membrane of the nose, and the discharge of fibrinous 
lumps through the anterior, or posterior, nares. It is sometimes accom- 
panied by repeated and perhaps fatal epistaxis. Sometimes there is- 
blocking up of the lachrymal duct, and consequent overflow of tears. 
Cases, indeed, occasionally occur in which the diphtheritic process ex- 
tends by this route to the conjunctiva, and a plastic exudation takes- 
place on that membrane. If the inflammation passes along the Eusta- 
chian tube, complaint will be made of roaring noises in the ears, of dart- 
ing pains, and of deafness, which may be followed by perforation of the 
membranatympani, and the discharge of a purulent fluid. 

Supposing that the disease has not attacked the larynx the third 
stage now sets in, and the disease pursues one of two courses: it may 
subside, and the patient may slowly recover; or it may quickly end- 
fatally. 

If the disease terminates favorably a marked improvement in all the 
s}*mptoms takes place generally at the end of the first or at the beginning 
of the second week. The swelling and injection of the mucous membrane 
steadily subside, the exudation ceases to extend, and portions become- 
successively loosened and are thrown off. All the local discomfort rapidly 
disappears, and the general symptoms improve. The temperature and 
pulse-rate fall to normal and remain so, the appetite returns, the urine 
becomes of natural color and quality, the skin resumes its functions, and 
with the exception of a certain degree of muscular weakness the patient 
feels quite well. He is not, however, as yet quite out of danger; it is not 
at all an unfrequent event for a relapse to occur, with afresh formation of 
false membrane, and a return of all the most serious symptoms; or the 
heart's action may show signs of failure, and he may die of syncope. Even 
if he escape these contingencies, he may at a later period experience the 
discomforts of diphtheritic paralysis. 

If the disease, instead of yielding, takes an unfavorable turn, the pa- 
tient may either sink from secondary blood-poisoning, with typhoid symp- 
toms, or coma may precede death; more often, however,, death occurs 
from cardiac embolism or simple syncope. 

(2.) In mild or catarrhal diphtheria the symptoms are often so slight 
that the practitioner hesitates to attribute them to a disease, the very 
name of which is heard with consternation. Indeed it is, as a rule, only 
when his attention is aroused by the proximity of other undoubted cases,, 
that he is at all likely to recognize the disease in its earlier stages. The 
symptoms are simply those of an ordinary catarrhal sore throat. The 
diphtheria, in fact, has been arrested at the first stage of its development. 
The constitutional disturbance is very slight; the temperature rises a 
degree or two above the normal, and the pulse is quickened in propor- 
tion. There is slight pain, and a feeling of dryness in the throat, and as a 



DIPHTHERIA. 103 

rule some degree of difficulty in swallowing. The submaxillary and cer- 
vical glands are not unfrequently swollen and tender. On inspecting the 
patient's fauces, no characteristic exudation is seen. The tonsils, soft 
palate, and back of the pharynx are of a bright red color, and somewhat 
swollen. In many cases the redness and swelling are limited to one side 
of the throat, the opposite side presenting an appearance of perfect health. 
At first the throat is dry, and there is a marked diminution in the quan- 
tity of the natural secretion; but this stage soon passes, and then minute 
accumulations of yellowish matter, not much exceeding the size of a pin's 
head, may be seen adhering to the surface of the tonsils, or to the pos- 
terior wall of the pharynx. These may be readily removed with a camel's- 
hair brush. As a rule the patients quickly recover, and by the third or 
fourth day may be declared convalescent. They often, however, suffer 
from a considerable degree of prostration during the illness, and a sense 
of weakness may remain for some days or weeks after the disappearance 
of the local affection. The symptoms above sketched are sometimes as- 
sociated with a trace of albumen in the urine, but occasionally the first 
evidence of the true nature of the throat affection is the occurrence of 
the characteristic paralysis. The appearance of one or other of these 
symptoms often forms the only clue which the physician has to the 
nature of the primary affection, which in all other respects, closely re- 
sembled a simple sore throat. In some instances, however, the catarrhal 
affection serves only to introduce the more serious form of the disease. 
In such cases, after the more trivial symptoms have lasted for three or 
four days, there is a sudden accession of fever, with marked constitutional 
disturbance and increase in the local symptoms. Exudation forms rap- 
idly in the throat, and with it the disease assumes all the characters which 
have already been described under " typical diphtheria." 

(3.) The inflammatory form of diphtheria is characterized by the 
active hyperemia which precedes, and accompanies, the exudation of 
lymph. On examining the throat, the appearance is that of acute 
pharyngitis, the mucous membrane of the uvula and fauces being greatly 
inflamed. Within twenty-four hours a thick false membrane usually 
covers the inflamed parts, but I have met with one case in which the 
exudation did not take place till four days after severe inflammation 
commenced. The tonsils are often increased in size, and the glands at 
the angle of the jaw are generally enlarged and tender. There is severe 
odynphagia. The pulse is very frequent, and the patient has a hot, dry 
skin, and often complains of great thirst. It is in this form of diphtheria, 
as Sir William Jenner ' has pointed out, that the joints sometimes be- 
come swollen and inflamed. 

(4.) In malignant diphtheria the attack begins with severe rigors, 
headache, and vomiting, and there is often also bleeding of the nose. 
The patient is at once, as it were, knocked down by the virulence of the 
disease. Throat-symptoms are not generally severe, but the secretions 
rapidly undergo decomposition, and cause the breath to have a most in- 
tolerable fetor. The temperature is not high, but the pulse is rapid, 
small, and irregular. Restless at first, the patient soon becomes apathetic 
and drowsy; his face grows pale, and his skin cold and clammy. The 
tongue is brown, dry, and tremulous, and sordes form upon the teeth. 
Hemorrhages may occur from the various mucous surfaces, and petechia? 
often appear beneath the skin. In short, all the symptoms of the typhoid 

1 Loc. cit. pp. 17, 18. 



104 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

state appear, and the patient finally becomes delirious and dies comatose, 
or succumbs to an attack of syncope. 

(5.) Gangrenous diphtheria is very rare in this country, except as a 
secondary phenomenon following scarlet fever. The process generally 
supervenes very rapidly after the formation of the false membrane, and 
the symptoms are such as have been described under putrid sore throat 
(page 30). These cases always terminate fatally. 

(6.) Chronic diphtheria is a more rare disease. In the years 1863 
and 1864 eleven patients (seven men and four women) came under my 
care in whose cases there was false membrane in the pharynx. In three 
of them at the same time there was deposit in the larynx. The patients 
were all able to attend as out-patients at the hospital, and though in 
several cases they were weak, yet they showed no very great degree of 
debility. In four instances there was albuminuria: in two of these it was 
intermittent and in two constant. The longest duration of any of these 
cases was three months, the shortest seven weeks, the average being 
fiine weeks. In all the cases, when the false membrane was mechanically 
Removed, bleeding occurred, and a fresh formation quickly took place. 
Various local treatment was adopted, but without any decided success. 
The power of maintaining the false membrane seemed to be lost after a 
time, and the lymph was at last separated without reproduction. Barthez ' 
has also described a case where the false membrane lasted for several 
weeks, and showed a highly persistent power of reproduction, and Isam- 
bert 3 mentions an instance in which a student became affected with nasal 
diphtheria, and continued for several months to expel pieces of false 
membrane on blowing" his nose. 

Some of the symptoms of diphtheria demand a more detailed discus- 
sion than has been accorded them above. 

The occurrence of albuminuria in cases of diphtheria was discovered 
by Dr. W. F. ^Vade, 3 of Birmingham, in the year 1857, and some months 
later it was independently observed by Dr. Germain See, of Paris. 4 In 
the greater number of cases of diphtheria the urine is found to be albumi- 
nous at some period of the disease. The albumen usually makes its ap- 
pearance within the first few days, and sometimes within the first twenty- 
four hours of the invasion, 5 but it may be delayed until as late as the 
third week. Its presence is rarely constant in any case. It may fluctuate 
considerably in quantity from day to day and from hour to hour, and it 
may disappear and reappear more than once before recovery sets in. The 
severity of the case furnishes us with no indication as to the probable 
occurrence of albuminuria; it has been searched for in vain in some most 
malignant cases, and it has been detected in the course of very mild at- 
tacks. It is never associated with any tangible amount of hematuria, 
but the urinary deposit usually contains hyaline, granular, and epithelial 
casts of the renal tubules. The urine itself is generally more or less 
highly colored, and of high specific gravity, and it contains a considerable 
excess of urea, as is the case in most other diseases of a pyrexial charac- 
ter. The albuminuria of diphtheria is almost always a transient phenom- 

1 Bull, de la Soc. Med. des Hop., 1858. 
- Lorain et Lepine : Nouveau Diet., 1869. 

3 Midland Quarterly Journal of the Medical Sciences, April, 1858. 

4 Union Medicale, 1858, p. 407. 

6 Dr Burdon Sanderson quotes a case in which, it appeared eighteen hours after the 
patient had been apparently in perfect health. Contributions to the Pathology of 
Diphtheritic Sore Throat, etc., Brit, and For. Med.-Chir. Rev., January, 1860. 



DIPHTHERIA. 105 

enon, and it is quite exceptional for it to persist after recovery. It sel- 
dom results in anasarca, and only very rarely in uraemia. In short, it is 
not by anv means a dangerous symptom, and recent observations have 
fully confirmed the dictum of Trousseau, 1 that it has only a limited signi- 
fication in relation to prognosis and treatment. 

The exudation of false membrane is an almost invariable phenomenon 
of diphtheria. There are only two classes of cases in which it may be 
absent, viz., those in which death from blood-poisoning occurs before the 
exudation has time to form, and those in which the local process is not 
severe enough to result in the formation of a definite membrane. This 
class has been described by Dr. Michel Peter 2 as " Diphtherite sine diph- 
theria." False membranes may form in the course of the disease upon 
any part of the mucous surfaces which are exposed to the air. As a rule, 
they attach themselves by preference to the more prominent parts. They 
may extend from the pharynx to the epiglottis and ary-epiglottic folds, 
and from thence by the ventricular bands and vocal cords, into the trachea, 
and may only be arrested in the smaller bronchi. They may spread up- 
ward into the nasal passages, covering the whole cavity and following the 
windings of the turbinated bones. They may appear at the orifice of the 
nares and attack the excoriated skin around them: they may extend up 
the lachrymal duct and show themselves upon the conjunctiva. In some 
rare cases they have been known to extend into the oesophagus, and they 
occasionally cover the tongue and the mucous membrane of the lips. In 
women who are suckling infants the disease sometimes appears on the 
nipple. In both sexes it may attack the mucous membrane near the ori- 
fice of any of the internal passages. External wounds of any sort are 
liable to be covered by false membrane. In short, no part of the body 
which is at once open to the air and uncovered by a thick epidermis, is 
free from the liability of local infection and the consequent formation of 
false membrane. The exudation may take place within a few hours of 
the invasion of the disease, or may be delayed for four or five days. The 
first sign of exudation consists in the infiltration of the superficial layers 
of mucous membrane with a yellowish substance, which raises the affected 
parts above the level of the surrounding surface. The further changes 
which take place have been already described. When the first membrane 
has been removed artificially, fibrinous exudation may again form, or the 
surface may gradually heal. When, however, the membrane has become 
detached of its own accord, recurrence in the same spot is rare. 

The symptoms of fever in diphtheria may either be very marked or al- 
most absent. In the severest and most malignant cases the temperature 
is often quite low. There is never any tendency to extreme hyperpyrexia. 
In the usual run of cases it would appear that the variations of temper- 
ature follow a fairly definite course. Trousseau states that there is a 
rather acute development of fever at the time of the attack, but that the 
feverish symptoms diminish on the second day, and cease on the following 
or next day. Wunderlich considers that the temperature in diphtheria 
is of little prognostic value, 3 but Faralli, to whom I have already referred, 
has shown that there is a definite pyrexial cycle in cases of diphtheria, 
which furnishes data both for diagnosis and prognosis. The observations 
which he has made prove that fever is a phenomenon commonly present 

1 Trousseau : Op. cit. vol. ii. p. 538. 

5 These de Paris, No. 270, Paris, 1859. 

3 Temperature in Diseases (New Sydenham Society's Translation), p. 367. 



106 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

in diphtheria. The elevation of temperature is rapid, and even in slight 
cases it frequently rises as high as 104° in a few hours, falling gradually 
until the normal point is reached on the fourth or fifth day. In cases of 
moderate severity the temperature again rises toward the fourth day, but 
seldom regains the height of the first elevation. The exacerbation is due 
to the appearance of fresh diphtheritic patches on parts previously healthy, 
or, more frequently, to the appearance of glandular enlargements, the re- 
sult of secondary infection. The effects of this secondary infection are 
clearly observed in severe cases which pass into the typhoid state. In 
these the temperature at first follows the same course as in the milder 
cases; that is, it rises rapidly and falls steadily until the third or fourth 
day. At that date it rises again, with some irregularity, but with a cer- 
tain relation to the extension of the local disease, and to the putrefactive 
changes in the membranes. In favorable cases a second steady fall suc- 
ceeds the second elevation, while in fatal cases the temperature continues- 
to rise until the last. The natural course of the temperature may at any 
time be modified by the supervention of impeded respiration, which will 
have the effect of reducing it. Dr. Faralli's observations were not simply 
confined to pharyngo-laryngeal diphtheria. In a case in which diphtheria 
affected a wound, he obtained the same results. The temperature rose 
within a few hours to over 105°, before the false membrane was clearly 
developed. It fell to normal on the third day, while the infiltration was 
at its maximum. 

Cutaneous eruptions are not uncommon in some epidemics of diph- 
theria, especially among children. Their most common situations are the 
neck and chest; occasionally they make their appearance on the face, 
abdomen, and thighs. A rash is most frequently met with in the sever- 
est cases. The date of its appearance is not definite, and its duration is 
very variable. Sometimes it disappears in a few hours, in other cases it 
persists for several days. The rash of diphtheria generally more or less, 
resembles the rash of scarlet fever, and consists of minute red isolated 
spots, which disappear on pressure. It differs from that of scarlet fever 
in the fact that it is never followed by desquamation. 

Sequelce. — Setting aside extreme debility and a disposition to cardiac 
syncope, which may be considered rather as characteristics of the disease 
itself, the only serious sequelae of diphtheria are various local paralyses. 
These paralyses are liable to follow any case, however slight; they may 
be partial or complete, and they may either limit themselves to single 
groups of muscles, or may involve in succession almost the whole volun- 
tary muscular system. Their advent is always gradual, and as a rule they 
declare themselves during the second or third week after the complete 
healing of the local lesion. Trousseau, 1 however, quotes a case in which 
they became manifest three days before the disappearance of the false 
membrane. On the other hand, they may be delayed until as late as the 
sixth week of convalescence. In any case their advance is gradual, and 
they may continue to extend for weeks after their first appearance. The 
muscles most frequently affected are those of the soft palate and pharynx, 
of the eye, and of the extremities. It is much more rare for the muscles 
of the larynx and trunk to be implicated, while those of the bladder and 
rectum are still more seldom affected, and those of the face, almost always,, 
though not invariably, escape. Concurrently with the paralysis, there is 
impairment of muscular, and sometimes of cutaneous, sensibility. The 

1 Gazette des Hopitaux, 1860, Nos. 1 and 5. 



DIPHTHERIA. 10 T 

muscles generally respond languidly to both galvanism and faradism,. 
while the patient complains of numbness and prickings in the paralyzed 
parts. More rarely there is pain or hyperesthesia. The affected muscles- 
occasionally undergo some degree of wasting, and in some cases their 
diminution in bulk is very considerable. The first muscles to be affected 
are usually those of the soft palate and pharynx, which are almost always 
affected more on one side than the other. 1 The soft palate and uvula hang 
loosely, and cannot be drawn up at will. There is often also some dimin- 
ished sensibility of the uvula, fauces, and epiglottis. The voice loses its 
resonance, and assumes a nasal character, while articulation is more or less 
embarrassed, and the patient is soon tired of talking. Swallowing is in- 
variably rendered difficult, and fluids frequently regurgitate through the 
nose, or pass into the larynx. Occasionally life can only be sustained by 
the use of the oesophageal feeding tube. The paralysis of the pharynx 
generally impedes expectoration, and the secretion accumulates in the 
throat, and causes considerable discomfort. 

Paralysis of the larynx is much less common than the palsies already 
described, but in rare cases it may appear even without other parts being 
affected. The paralysis may involve the whole muscular apparatus of the 
larynx, or may limit itself to single muscles. In the former case the vocal 
cords will be seen on laryngoscopic examination to remain motionless 
during phonation, occupying the post-mortem position. The voice is al- 
most entirely lost, and any increased exertion leads to considerable dysp- 
noea, not from paralysis of the abductors, but from loss of power of the 
adductors, and consequent inability "to hold the breath — " an act which 
is especially necessary for delicate persons when making an effort. The 
muscular paralysis is occasionally associated with loss of sensibility of the 
mucous membrane of the epiglottis, in which case portions of food are 
more likely to make their way into the larynx than when the pharynx 
alone is affected. Such an accident may give rise to very serious symp- 
toms. Where the paralysis only involves single muscles, it is the abduc- 
tors which generally suffer, but often only one cord is affected. Two- 
cases of permanent paralysis of the recurrent nerve, following diphtheria,, 
have come under my notice. 

Usually, the sense of taste is more or less blunted, and there is a loss. 
of sensibility in the veil of the palate. In other cases the patient com- 
plains of numbness and a pricking sensation in the tongue and soft pal- 
ate. The muscles of the eye are the next to suffer. Indeed, in some 
cases, they become paralyzed at the same time as the muscles of the pal- 
ate. The patient first notices that it is getting more and more difficult 
for him to read small print. The effort tires him, and causes pain in his 
eyes; soon his vision becomes quite indistinct, and he suffers from flashes 
of light before the eyes. He does not, however, lose the pow r er of seeing- 
distant objects. At a later period there may be double vision, giddiness,, 
and squinting, from palsy of the oculo-motor muscles. The earlier symp- 
toms are due, according to Donders, 2 to impairment of accommodation 
from palsy of the ciliary muscles. The chief affection of the sense of 
sight, therefore, depends on paralysis of parts supplied by the. lenticular 
ganglion of the sympathetic chain, as the pharyngeal paralysis appears, 
to be due to impairment of Meckel's ganglion, and these facts have led 
Dr. Hughlings Jackson 3 to inquire, in cases of diphtheritic paralysis, for a 

1 See p. 85. 2 New Sydenham Society's Translation, 1864. 

3 Ophthalmology in its relation to General Medicine : British Medical Journal, May 
12, 1877, p. 505. 



108 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

corresponding affection of the sense of hearing, such as would be likely 
to result from interference with the function of the otic ganglion. He 
has hitherto only met with one such case, that of a medical man. The 
affection was not sufficient to impair his hearing for ordinary purposes, 
but " enough to render music unintelligible." In fact, as Dr. Jackson 
says, we should not expect deafness as the result of diphtheritic paraly- 
sis, but only slight interference with the power of appreciating high- 
pitched sounds. It is impossible to tell as yet how frequent such an af- 
fection may be in cases of diphtheritic paralysis. As far as our knowledge 
at present goes, it is little more than a pathological curiosity. Next in 
order to the muscles of the eye, those of the extremities most frequently 
show signs of paralysis. The lower extremities are usually the first to be 
affected. The patient first suffers from numbness and tingling in the 
feet. Soon, on attempting to w T alk, his legs begin to tremble, and he feels 
as though he were walking on air. The difficulty gradually increases, his 
movements grow more and more clumsy, until at length he loses all power 
over his legs, and becomes a helpless cripple. The muscles of the affected 
parts feel flabby to the touch, and they refuse to respond to the electric 
current. Cutaneous sensibility is also much impaired, or entirely abolished, 
especially in the soles of his feet. The same symptoms may occur in the 
•upper extremities. There is, first, numbness and formication in the 
fingers, then increasing clumsiness of movement, and finally, complete 
paralysis. 

The last muscles to be affected are generally those of the neck and 
trunk. Paralysis of the former in its worst forms deprives the patient of 
the power of raising or turning his head, which falls helplessly backward, 
forward, or to one side. Paralysis of the latter renders turning or mov- 
ing in bed impossible, and at the same time causes considerable embar- 
rassment to respiration from the implication of the intercostals. When 
the diaphragm is also paralyzed, as in rare cases it is, the difficulty of 
breathing is enormously increased, and the patient runs the greatest risk 
of dying from asphyxia. If, however, the paralysis be not complete, the 
danger may be warded off, and the patient may gradually recover. Con- 
currently with the paralysis of the extremities in the most severe cases, 
there is often incontinence of urine and faeces from palsy of the sphincters 
Df the bladder and rectum. In men the sexual function is also affected in 
Buch cases, and the patient becomes temporarily impotent. 

Having continued for a period varying from six weeks to half a year, 
these paralyses gradually disappear in the order in which they appeared, 
the duration being in each case proportionate to the degree of paralysis, 
if no unfortunate complications lead to a fatal result, eventual recovery 
of muscular power may almost invariably be counted upon; but in most 
cases the patient continues for a long time to experience some degree of 
weakness in the affected parts. Lastly, it is well to remember that the 
severity of the paralytic symptoms bears no proportion whatever to the 
severity of the antecedent disease. The loss of power may occur in a 
marked degree after even the most trivial attacks. 

Diagnosis. — In some cases of diphtheria an absolute diagnoses may be 
almost a matter of impossibility, at any rate in the earlier stages of the 
disease. The difficulty generally arises in those cases which deviate from 
the normal type in the direction either of unusual mildness or of unusual 
severity. Very mild cases, in which the false membrane is either abseni 
or late in appearing, may easily be confounded with ordinary catarrhal 
sore throat. The diagnostic criteria are both few and indefinite. A his- 



DIPHTHERIA. 109 

tory of infection, or the epidemic prevalence of diphtheria, may in some 
cases be of service in forming an opinion, but more oftener the practi- 
tioner has to trust to other data. In the case of the diphtheritic sore 
throat, without false membrane, the congestion is at once more limited 
and more intense than in pharyngeal catarrh; it often affects one lateral 
half of the soft palate, or one tonsil, while the catarrhal process has usu- 
ally a more general distribution. In simple sore throat the surface of 
the tonsils may be covered here and there with patches of deposit, which 
might possibly mislead an ignorant or incautious observer; but such de- 
posits will invariably be found to be soft, semi-fluid, and easily removed. 
They are, in fact, nothing more than the modified secretion of the con- 
gested mucous structures. In diphtheria, moreover, there is often albu- 
minuria, and a degree of prostration out of proportion to the severity of 
the local changes. In many cases, in the absence of false membrane, the 
practitioner must rest content with a diagnosis founded upon unsatisfac- 
tory criteria. In other cases, however, the sudden development of exuda- 
tion and the appearance of serious symptoms of general infection may 
clear up all doubt; while in still rarer instances the supervention of mus- 
cular paralysis during convalescence will solve the problem in a quite un- 
expected manner. It is hardly necessary to add that, in all cases of sus- 
pected diphtheria, it is the bounden duty of the practitioner to make a 
most thorough examination of the interior of the throat, supplementing 
it, if possible, by the use of the laryngoscope and rhinoscope. These in- 
struments will often bring to light patches of exudation, and will thus 
give very material help toward a satisfactory diagnosis. 

The cases in which diphtheria appears in an exceptionally severe form 
may offer still greater difficulties in the way of diagnosis than even mild 
cases. A patient, for instance, is suddenly struck down by intense 
general blood-poisoning, and rapidly passes into what is named the 
typhoid state. If inspection of the fauces is neglected in such a case, the 
physician may experience the greatest perplexity as to the nature of the 
disease. Even the fauces may appear healthy, and the case be still one 
of diphtheria; for the membrane may not as yet have had time to form, 
or may have formed beyond the range of sight. The only aid to diag- 
nosis in such a case will be found in the character of the prevailing 
epidemic. Malignant diphtheria very rarely occurs in an endemic form. 

Apart from the above difficulties, diphtheria may simulate, and be 
simulated by, scarlet fever, confluent herpes of the throat, acute tonsilli- 
tis, and acute laryngitis. There can be no doubt that, in many cases, 
diphtheria has been mistaken for scarlet fever. The severe constitu- 
tional disturbance, the sore throat, and the rash, which is a common symp- 
tom in some epidemics of diphtheria, are all liable to mislead the observer. 
But the points of difference are fairly well marked. The constitutional 
symptoms are usually slighter in diphtheria; there is, as a rule, less ano- 
rexia, but more prostration. The throat in scarlet fever is uniformly 
reddened, and if it be the seat of any membraniform deposits, these are 
soft and easily detached. The larynx, moreover, is only very exception- 
ally attacked. There may be albuminuria in either disease, but hnematu- 
ria, which is scarcely ever known to occur in diphtheria, is not uncommon 
in scarlet fever. The distinctive characters of the rashes have already 
been described. 

Acute tonsillitis at its outset may simulate the inflammatory form of 
diphtheria. In both there is considerable constitutional disturbance and 
difficulty of swallowing; in both the throat affection has a more or less lini- 



110 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

lateral tendency, and commences with intense congestion. In tonsillitis, 
however, the inflammation either subsides, or rapidly passes into suppura- 
tion, and thus removes all cause of difficulty. 

Confluent herpes of the throat is not a common disorder, and is not, 
therefore, often likely to give rise to difficulties in practice. Trousseau, 1 
however, lias laid down the diagnostic distinctions between the two dis- 
eases with considerable detail. Herpes is usually ushered in with consid- 
erable constitutional disturbance, but the temperature rarely rises higher 
than 102° or 102.5° Fahr., and it quickly subsides. The pain in the 
throat is of a peculiar smarting character. Herpes has no tendency to 
spread beyond the seat of its first efflorescence. Thus, if in a doubtful 
case the morbid process is found extending to the tonsils, to the larynx, 
or to the nose, herpes may be excluded. Of course the simultaneous ap- 
pearance of herpes on the hip will be of great help in forming a diagno- 
sis. 

The diagnostic distinctions between laryngeal diphtheria and catarrhal 
laryngitis will be found under the head of " Croup." 

Pathology. — The characteristic product of diphtheritic inflammation — 
the false membrane — is a tough dry substance resembling fibrin, or the 
buffy-coat of the blood. In color it is yellowish, or grayish white; it is 
firm and elastic, but it breaks across suddenly when stretched. The addi- 
tion of acetic acid causes it to swell up and become transparent; it is 
dissolved by caustic alkalies. It is insoluble in water, and yields to it 
neither gelatine nor albumen. It thus closely resembles fibrin in most of 
its qualities. The membrane may vary from a thin and transparent pelli- 
cle to a skin of considerable thickness. The character of the exudation 
varies according to its age. In the earlier stages the different patches of 
membrane are more or less isolated, they are surrounded by mucous mem- 
brane in a state of intense hyperemia, they project only very slightly 
above the mucous surface, and they cannot be removed without considera- 
ble force. Later on, the patches are found to have coalesced, they have 
become firmer and thicker, and evidently project higher above the sur- 
rounding surface. In the next stage these edges become loosened, and 
show a tendency to curl up, giving the exudation a more or less* cupped 
appearance. Pus gradually accumulates beneath it, until it detaches 
itself, leaving the subjacent mucous membrane in a state of catarrh. 

According to the most recent researches, the exudation in pharyngeal 
diphtheria is seen under the microscope to consist exclusively of cells. 
The naked-eye resemblance to coagulated fibrin is due to a peculiar de- 
generation of the epithelial cells, and to an equally peculiar fusion of 
them one with another. The cells manifestly contain more solid matter 
than normally, but the precise character of the infiltration is as yet uncer- 
tain. On examining a section of membrane under the microscope, it is 
seen to consist of thin changed cells, fused together in various directions, 
and leaving a system of branching fissures, which permeate the whole 
membrane. The most superficial cells are twice as large as lymph cor- 
puscles. They gradually decrease in size as we proceed deeper, until 
those which are in immediate contact with the mucous surface are almost 
indistinguishable from normal cells. Here and there, scattered through- 
out the membrane, are often seen minute extravasations of blood, which, 
•originally formed on the mucous surface, have become separated from it 
-and encapsuled by successive layers of degenerated cells. To sum up in 

1 Op. cit. , vol. ii. p. 439. 



DIPHTHERIA. Ill 

the words of Rindfleisch, 1 " the false membrane is undeniably produced 
by the separation of young elements from the irritated mucous surface 
and by their gradual stiffening, sclerosis, glassy swelling, or whatever 
term we may choose to apply to their degeneration." In course of time 
the mischievous process comes to a standstill. The cells secreted by the 
mucous membrane no longer undergo the abnormal degeneration; pus 
ceils appear in increasing quantities between the mucous surface and the 
false membrane, and soon lead to the final separation of the latter. The 
exudation also disappears to some extent by undergoing a process of 
softening, the cells becoming granular and fatty, and the network under- 
going gelatinous degeneration. This, though not an uncommon termi- 
nation in favorable cases of tracheal diphtheria, is much rarer when the 
false membrane is formed in the pharynx. 

In describing the symptoms of diphtheria, it has been pointed out 
that in the earliest stages of the disease the mucous membrane is inflamed 
and swollen, but is soon coated with false membrane, and becomes hidden 
from view. If the disease progresses favorably and the case is not very 
severe, on separation of the lymph, the mucous membrane is seen to be 
smooth, and often somewhat paler, than in a state of health; but, if the 
affection has been at all violent, more or less ulceration of the mucous 
membrane will be present. Occasionally the morbid process does not stop 
at ulceration, but gangrene results, and there is considerable loss of tis- 
sue. In many fatal cases the gangrenous process is in active operation, 
and its peculiar odor becomes evident on the post-mortem table, if not 
during life. The idea entertained by the ancient physicians, that the 
disease was a gangrenous process, was, it need scarcely be observed, 
derived from the appearance of the false membranes themselves, which, 
whether white or subsequently discolored, have very much the aspect of 
an eschar or slough. This is, of course, only a delusive appearance, 
and our modern knowledge of the gangrenous process in diphtheria 
is based on the post-mortem examination of the tissues beneath the false 
membrane. In the severer forms of the disease there is, in addition to 
the changes above described, an exudation of fibrin into the subepithelial 
connective tissue. The exudation and infiltration sometimes compress the 
nutrient vessels of the part, and thus arrest its blood supply. Necrosis 
of the involved tissues results, and leads to the formation of a slough, 
which is, in course of time, separated from the healthy parts. On the 
slough becoming finally detached, there is left an ulcer of variable depth 
and extent. In several cases I have known the patient recover with the 
loss of his uvula, and with a portion of one or both tonsils destroyed. It 
is more common, however, in cases of recovery after gangrene to find 
large and puckered cicatrices resembling those which are seen as the result 
of syphilitic ulceration. 

In addition to the inflammatory products of diphtheria, there are cer- 
tain parasitic phenomena. The idea that diphtheria is of parasitic origin 
was first put forward by Professor Laycock 2 and subsequently revived by 
Jodin. 3 More recently Oertel 4 has maintained the parasitic theory with 
great vigor, and has been followed by many German observers. Oertel 



1 Lehrbuch der Pathol. Gewebelehre, II. Auflage, p. 310, Leipzig-, 1871. 

2 Medical Times and Gazette, May 29, 1358. 

3 De la nature et du traiteraent du croup, etc. : Revue Med. , t. i. pp. 22 and 134, 
Paris, 1859. 

4 Zierasten's Cyclopaedia of Medicine, vol. i. p. 589. 



112 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

contends that certain definite forms of vegetable life, especially the 
spherical bacteria, called micrococci, and the smallest forms of bacterium 
termo, are invariably associated with the diphtheritic process. The gray- 
ish white hoarfrost-like patches which appear on the mucous membrane 
at the very commencement of the disease, contain, he says, luxuriant 
growths of micrococci. They are always present in diphtheritic mem- 
branes, and they are also found in varying quantity in the blood, when- 
ever such membrane exists. The quantity of them present in any case, 
moreover, bears, it is affirmed, a direct relation to the intensity of the 
morbid processes; they multiply as the disease advances, and diminish 
w^ith its retreat. Oertel states that the special form of micrococcus is 
never present in simple inflammation of the fauces or in mercurial stoma- 
titis; but, that if the diphtheritic process supervenes on these disorders, 
it at once makes its appearance, and quickly displaces the more common 
forms of bacteria previously present. According to Oertel, and some 
other experimentalists (see Etiology), after the inoculation of the different 
tissues of animals with diphtheritic exudation, it has been found that the 
micrococci force their way amongst the cellular elements, crowd into the 
blood and lymph vessels, which they render impermeable, infiltrate the 
muscles, and lead to their degeneration, and even reach the kidney, where 
they excite the inflammation which is so common a complication of diph- 
theria. Eberth ! has gone so far as to declare that without micrococci there 
can be no diphtheria ; while in Italy Giacchi 3 believes that a parasite is 
as necessary in the pathogenesis of the disease, as the o'klium vitis is in the 
production of disease of the grape. Letzerich 3 has found another fungus — 
the zygodesmus fuscus — which he believes is the essential cause of the dis- 
ease. The conclusions of Oertel and Letzerich have, however, been directly 
controverted by Senator, 4 who has found the leptothrix buccalis in diph- 
theria, and who considers the minute round bodies described by Oertel (as 
the spherical bacteria) to be the spores of the leptothrix. According to 
Senator the same fungi are found in diphtheria as in ulcerative, aphthous, 
and mercurial stomatitis. In February, 1874, I examined seven cases- 
for epiphytes, and succeeded in finding what is commonly described as 
" the leptothrix buccalis " in five instances. In every case, however, the 
fungus was in the superficial layer of the lymph. The importance of the 
presence of fungi in diphtheritic deposits is controverted by Dr. Beale/ 
whose authority as a microscopist must carry great weight in this coun- 
try. This observer maintains that " vegetable germs are present in every 
part of the body of man and the higher animals, probably from the earliest 
age, and in all stages of health. . . . Millions of vegetable germs are 
always present on the dorsum of the tongue and in the alimentary canal." 
Dr. Beale further states 6 that " active bacteria introduced amongst the 
living matter of healthy tissues will die, although the most minute germs. 
present which escape death may remain embedded in the tissue in a per- 
fectly quiescent state." He thinks also " that there are very few morbid 
conditions that are unquestionably solely due to the growth and multipli- 
cation of vegetable fungi." 7 

The changes which may take place in other tissues in the course of an. 



1 Zur Kenntn. der bacterit. Mykosen, 1872. 

2 Natura e Terapia dell' angina difterica: Lo Sperimentale, Nov. 1872. 

3 Virchow's Archiv., Bd. xlv. et seq. 

4 Archiv. fur Pathol. Anatomie u. Physiol., Bd. lvi. No. 12, 1872. 

5 Disease Germs, London, 1872, p. 65 et seq. 

6 Ibid. p. 71. 7 Ibid. p. 78. 



DIPHTHERIA. 113 

attack of diphtheria are very various : The parotid and submaxillary 
glands which Dr. Samuel Bard ! first pointed out as being frequently 
swollen, have been recently shown by Doctors Balzer and Talamon 2 to 
be the subject of distinct pathological changes. The cells of the acini 
are generally either swollen and filled with a homogeneous mucoid mate- 
rial, or replaced by quantities of small round cells. Here and there are 
also frequently minute collections of pus. The lymphatic glands of the 
neck are almost invariably found to be more or less enlarged. On section 
they are redder than natural, and there is an evident increase in their 
cellular elements. The tissues around them, which during life were 
brawny and tender, are found at the autopsy to be infiltrated with serum 
and with scattered pus-cells. Often they present minute extravasations, 
while, in rare cases, considerable masses of blood have been found effused 
in the cellular tissue surrounding the glands. 

The lungs may be the seat of very varied changes. The bronchial 
tubes are always inflamed — the inflammation generally being catarrhal, 
but sometimes purulent ; in many cases, however, it is plastic, and then 
most commonly occurs on the fourth or fifth day of the disease. On lay- 
ing open the bronchi, the false membrane is found attached to- their walls, 
or lying loose in their channels. The membrane is never equally ex- 
tended throughout the whole system of tubes, but seems to have a pre- 
ference for those branches which run in a vertical direction. The fact of 
one of the lungs being bound down by pleuritic adhesion would seem es- 
pecially to attract the morbid process in that direction. Exudation is 
not unfrequently found to extend to the minutest bronchial ramifications, 
in which case the alveoli are usually more or less implicated, and contain 
fibrinous threads, pus-cells, and, in some cases, blood corpuscles. As a 
rule, the lungs are more or less engorged and oedematous, especially at 
their bases ; and frequently there are extensive patches of pneumonia of 
a low type, with emphysema, or more often mere insufflation of the air 
cells 3 in the immediate vicinity. In other cases scattered lobules are 
found collapsed and void of air from occlusion of the smaller bronchi, 
or one of the lobes is the seat of more or less extensive pulmonary apo- 
plexy. According to Peter, 4 59.50 per cent, of the cases of broncho-pneu- 
monia occur between the second and the sixth day. The heart has often 
an appearance of perfect health, but, in cases where death has occurred 
from general blood-poisoning, its muscular tissue is soft and friable, and 
contains scattered extravasations of blood. Under the microscope the 
muscular fibres show signs of fatty degeneration, and the blood is fluid 
and tarry. In other cases the opposite condition is sometimes found, 
coagula of considerable size being met with in the cavities of the heart 
and in the large vessels. 5 

The spleen and liver are often perfectly natural, but occasionally they 
are much engorged, and sometimes their capsules present extravasations 
of blood. The inner surface of the stomach may be the seat of ulcers 
and sloughs, and hemorrhagic exudations are occasionally met with, both 
in that situation and beneath the lining membrane of the intestines and 
bladder. The kidneys present marked changes in about half the fatal 
cases of diphtheria. They are swollen and engorged, and often contain 



1 Loc. cit. 2 Revue Mensuelle, le 10 juillet, 187S. 

3 Jenner: Loc. cit. p. 38. 4 Gazette hebdom.. 1804. 

5 Richardson : Med. Times and Gaz., 1856. Meigs : American Journ. of Med. Sci. 
April, 1864. Beverley Robinson : These de Paris, 1866 ; and other authors. 



114 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

scattered collections of blood. In other cases the changes are only visi- 
ble under the microscope. Here the epithelial cells lining the tubules 
are found swollen and granular, and they have often undergone extensive 
proliferation, the crowded masses of young cells filling the tubes, and 
forming epithelial casts. Occasionally the Malpighian tufts and the 
tubules contain blood, and the latter are sometimes occupied by hyaline 
coagula. 

The changes in the brain depend on the mode of death, and, if the 
patient succumbs to asphyxia, there is venous engorgement of the mem- 
branes and cerebral substance, and minute extravasations of blood. Pus 
and lymph have also been found on the arachnoid membrane, when the 
septicaemia has been very marked. In many cases where death has taken 
place whilst the patient was suffering from extensive diphtheritic par- 
alysis, the muscles have presented no marked alterations ; ] and Morelli 2 
goes so far as to say that " the anatomico-histological changes found in 
such cases are inadequate to explain the various forms of diphtheritic 
paralysis and paresis." In fact, the almost invariable restoration of these 
functions would seem to argue conclusively against these muscles being 
the seat of any serious degenerative change. In exceptional cases, how- 
ever, serious and extensive lesions have been discovered. They were 
first observed by Charcot and Vulpian 8 in a case of paralysis of the velum 
palati. The motor nerves of the part consisted of tubules emptied of 
their medullary substance, their neurilemma containing numerous granu- 
lar, cells, elliptical in form, and in some instances nucleated. In one 
case Buhl 4 found the nerves thickened at their roots, and the sheaths of 
the nerves crowded with lymphoid cells and nuclei. In a case of Oertel's 5 
the muscles had undergone extensive fatty degeneration, while the sub- 
stance of the brain, spinal cord, and spinal nerves was the seat of numer- 
ous extravasations of various dates. There were also other marked 
changes in the spinal cord. Dr. Hughlings Jackson 6 has pointed out that 
muscles supplied in part through ganglia of the sympathetic system are es- 
pecially prone to be the subject of paralysis. This is true of diphtherial 
amaurosis, and of the paralysis of the palate, and it would seem that the 
nerve-cells which give way are most largely represented in the higher 
ganglia of the sympathetic systems. 

The most cursory study of thegeneral pathology of diphtheria suffice* 
to assure us that it is an acute general disease, with certain local manifes- 
tations, ^hs primary septicaemia is due, in the first instance, to the speci- 
fic poison, but absorption from the decomposing lymph is no doubt also 
a cause of secondary infection. In all cases the attack is associated with 
some degree of constitutional disturbance, while in the severest forms 
there is extreme disorganization of the blood and consequent implication 
of nearly every tissue in the body. The general infection is shown at a 
very early stage, as well as at a period when the local manifestations have 
disappeared. Besides the constitutional disturbance by which the attack 
is ushered in, there is the frequent derangement of the renal function, the 
marked prostration of strength, the functional disturbance of the heart, 
and at a later period the extensive implication of the nervo-muscular sys- 



1 See two cases reported by Dr. Hermann Weber : Vircbow's Archiv, vol. xxiii. p. 
115. 

a Lo Sperimentale, Dicembre, 1872. 

3 Compt. rend, de la Soc. de Biol., 1862. 

4 Ziemssen's Cyclopaedia, vol. i. p. OoO. 

6 Ibid. p. G57. 6 Loc. cit. 



DIPHTHERIA. 115 

tem. The local symptoms — the false membrane with its parasitic 
growths — must be looked upon as the first evidence of constitutional 
poisoning, in fact, as the first of the secondary phenomena. 

Pi'ognosis. — The mortality of diphtheria varies chiefly according to 
the age of the patient and the character and stage of the epidemic, and 
these points must consequently be borne in mind in giving a prognosis. 
The relative proportion of deaths to cases is by no means constant. In 
some epidemics it has exceeded 50 per cent. According to Dr. Borgiotti's 
statistics ' of the recent Florentine epidemic, out of 1,54G persons at- 
tacked in the years 1872 and 1873, 881 died ; but as Dr. Borgiotti else- 
where 2 remarks, owing to the incompleteness of the health-returns, or, 
in other words, the probable omission of slight cases, these figures should 
be looked upon rather as the relation of " the gravely affected to the 
dead. " 

The dangers which are most to be dreaded at the outset of an attack 
are, on the one hand, extension of the disease to the larynx, and, on the 
other, the severe blood-poisoning. In the former case the patient is ex- 
posed to imminent risk of death from asphyxia. In the latter a fatal re- 
sult may occur from collapse, or the patient may rapidly sink with typhoid 
symptoms. At a later period, a fatal result may be brought about by re- 
peated attacks of syncope, by general prostration without manifest cause, 
by exhaustion from constant and uncontrollable vomiting or from severe 
hemorrhages, or by inflammatory complications such as secondary pneu- 
monia or acute nephritis, in the case of infants, death has resulted from 
inability to suck, owing to implication and consequent stoppage of the 
nasal passage. Death during convalescence most commonly results from 
paralysis of the heart, or of the muscles of inspiration, or from intercur- 
rent disease of the lungs or pleura, or from general failure of nerve-force 
and exhaustion. 

With regard then to the data on which a prognosis must be formed, 
the most important general consideration is the character and mortality 
of the prevailing epidemic. It may, perhaps, be laid down as a rule that 
of the cases in which a definite false membrane is present, one-third at 
least will probably prove fatal. Apart from other less known causes, the 
mortality in any epidemic will vary according to the form of the disease 
and according to the proportion of children to adults attacked, diphtheria 
being, for obvious reasons, far more fatal amongst children than adults. 
It must also be borne in mind that in certain families diphtheria has an 
exceptional tendency toward a fatal result. With regard to the special 
symptoms on which to found a prognosis, the following considerations 
chiefly deserve attention: High temperature, extreme prostration, hemor- 
rhages, or urgent vomiting at the commencement of an attack are signs 
indicative of extensive general infection, and must therefore be looked 
upon as of very serious prognostic import. Valuable information may be 
gained from the character and extent of the false membrane. Ceteris 
paribus, the prognosis is serious in proportion to the thickness and ex- 
tent of the, exudation. When the exudation shows a disposition to ex- 
tend rapidly, the danger is very considerable, as the extension is very 
likely to take place in the direction of the larynx. Prostration and a 
tendency to syncope are alarming signs at any period of an attack; their 
advent is often heralded by a very rapid or a very slow pulse, with muf- 
fling of the heart's sounds, and intermittency of its pulsations. The 

1 Loc. cit. 2 Atti dell' Accademia, etc. p. 16. 



116 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

presence of albumen is not, as I have already pointed out, a symptom of a 
serious import. During convalescence the extension of muscular paraly- 
sis to the muscles of respiration is the most alarming sign. 

Treatment. — The symptoms of diphtheria are due, as I have shown, 
in part to a general blood infection, and in part to a local specific inflam- 
mation. Each of these pathological processes appears to run a cyclical 
course; in each the deviation from health is only a temporary one, which 
after lasting for a variable period, shows a tendency to subside and to 
terminate in the re-establishment of normal action. Each process, how- 
ever, is attended with its own special danger, which may lead to a fatal 
issue before the return to health. As regards the general condition it is 
the intensity of the morbid changes which constitutes the great danger; 
locally, the risk lies in the occurrence of the exudation in a perilous situa- 
tion. The main objects in the treatment, therefore, will be to offer every 
possible resistance to the dangers arising out of these features. This will 
be accomplished in part by general and in part by local means, and nei- 
ther form of treatment must be neglected. 

General Treatment. — This should be directed toward husbanding and 
supporting the patient's strength by every available means. He should 
be placed, if possible, in a large, cheerful, and well-ventilated room, the 
air of which must be at once warm and moist. The temperature should 
be kept as nearly as possible between 00° and G5° Fahr. The patient's 
diet must be at once nutritious and digestible. Concentrated beef-tea, or 
beef-tea jelly, milk, and egg-flip must be regularly given at short intervals. 
Dr. Massei, 1 who has seen a great deal of the disease at Naples, has pointed 
out that milk is often digested with difficulty in these cases, and under 
such circumstances it must be combined with lime water. Especial at- 
tention must be paid to feeding during the night, when the vital power 
of the patient is usually at its lowest ebb. There is often great distaste 
for food; in other cases swallowing is attended with considerable pain, 
while occasionally everything that is swallowed is immediately rejected. 
It is, however, the duty of the attendants to secure the due nourishment 
of the patient in spite of every difficulty. There are few cases of diph- 
theria in which systematic feeding does not constitute the most important 
part of the medical treatment. The administration of alcohol in small 
quantities is almost always advisable. In some cases, it is true, it may 
not be called for during the whole of the attack, but very often it sup- 
plies us with the best chance of saving the patient's life, and it must 
then be pushed with a boldness rarely needed in other forms of disease. 
Small doses of alcohol will usually be found sufficient in the earlier stages 
of an attack; two ounces of brandy or four ounces of wine in the twenty- 
four hours may be prescribed for an adult, and proportionate quantities 
for a child. In other cases, however, larger doses are required from the 
very commencement. But whatever be the earlier symptoms the physi- 
cian must always be prepared to increase the dose rapidly, if the appro- 
priate indications — attacks of syncope, irregular, very frequent, or very 
slow pulse, and delirium — present themselves. In these circumstances a 
high temperature does not in itself contra-indicate the employment of 
stimulants. In all cases it is necessary to keep a careful watch upon the 
pulse, which will give invaluable information as to the need for alcohol. 
Rapid and fatal failure of the heart often supervenes quite suddenly and 
unexpectedly, and the first indication of such failure is the signal for the 



Intorno alia Cura dell' Angina Difterica, Napoli, 1875, p. 54. 



DIPHTHERIA. 117 

unsparing use of the drug. Patients suffering from the exhaustion and 
prostration of diphtheria bear large amounts of stimulant without any of 
the usual intoxicating effects, and as much as twenty ounces of brandy 
have been given to an adult within twenty-four hours with manifest bene- 
fit. Champagne may occasionally be substituted for brandy, but this 
wine, in the active state of the disease, often causes pain in deglutition., 
and, as a rule, is more useful during convalescence. Whenever there are 
signs of approaching cardiac failure, it is important to keep the patient 
in bed with his head low, and to interdict any movement whatever. The 
neglect of this precaution has often been attended with fatal results. 

Before passing to the strictly therapeutic treatment it is necessary to 
make a few remarks on bloodletting-. It was at one time thought that 
general bleeding had a favorable influence on the spread of the exudation. 
Home strongly advocated it, and recommended in addition the applica- 
tion of leeches to the upper part of the throat. Bretonneau invariably 
used the lancet in his earlier cases. But experience soon taught him that 
depletion neither extinguished the disease nor prevented the formation 
of false membrane, and he reluctantly abandoned it. Guersant, Trous- 
seau, Bouchut, and Empis all came to a similar conclusion, and since their 
time the treatment by venesection has not been revived. Considering the 
serious danger of death from syncope and exhaustion to which patients are 
exposed when suffering from diphtheria, it is a matter for wonder that 
such treatment was ever thought of. The only rational excuse for its 
adoption was the theory that it prevented the extension of the local pro- 
cess. It has now, however, been almost universally admitted that general 
bloodletting has no influence whatever, unless it be an injurious one, 
upon the exudation. The same may be said, with scarcely less emphasis, 
of local depletion. The application of leeches to the throat may indeed 
relieve the pain and swelling, but such relief is dearly bought at the loss 
of even small quantities of blood, and the serious risk of diphtheritic in- 
fection of the leech-bites. 

Of the general remedies which have been recommended in diphtheria 
there are four kinds, viz. : (1) The recuperative agents; (2) the alleged 
specifics; (3) the antiseptics; and (4) the expectorants. Some remedies, 
it will be at once perceived, belong to more than one of these divisions. 

(1.) Of the recuperative agents iron and quinine are the most entitled 
to consideration. Of these iron is undoubtedly the most useful, and the 
profession is indebted to Dr. Heslop, 1 of Birmingham, for proving its 
value in diphtheria. It should be administered frequently and in large 
doses. Thirty minims of the tincture of the perchloride may be given to 
adults every two or three hours, and proportionate doses to children. It 
is well to combine it with glycerine, and, of course, it must be diluted 
with water. The general effect of the drug is often extremely favorable, 
and its influence is equally well marked, the soreness and pain in the 
throat being considerably relieved after each dose. The double effect is 
more surely procured by prescribing one of the persalts in preference to 
the less astringent protosalts. Quinine is occasionally required in the 
course of an attack of diphtheria. The special indications for its use are 
headache with high temperature, vomiting, and the symptoms of septic 
poisoning. In such cases the drug should be given in full doses, and should 
not be persisted in if benefit fails to result in thirty-six, or at the most, 
forty-eight hours. As a rule, however, quinine is more useful after the 



1 Medical Times and Gazette. May 20, 1858. 



118 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

more serious symptoms have abated, when it may be very suitably com- 
bined with iron and a mineral acid. Morphia and chloral are occasionally 
necessary to combat continued sleeplessness, and to ward off the exhaus- 
tion which is its invariable consequence. 

(2.) The principal alleged specific remedies are : mercury, sulphide of 
potassium, bromine, and the balsams of copaiba and cubebs. The treat- 
ment of diphtheria by mercurials was at one time not less common than 
the practice of depletion, and it received a certain degree of support from 
the favorable influence which dusting with calomel is found to exert on 
diphtheritic wounds. But experience has long taught us that the gener- 
al influence of mercury on the system rather promotes than checks the 
spread of the exudation. At one period mercury was vigorously pushed by 
Bretonneau, 1 but with very unsatisfactory results. From that time the 
use of mercury has been gradually discarded, and with such general con- 
sent that no one has since ventured to reintroduce it. Of the other al- 
leged specifics, sulphide of potassium has long been regarded by Swiss 
physicians as a valuable specific, but it often produces both sickness and 
diarrhoea, and should not be employed. Bromine, which is best adminis- 
tered in the form of bromide of potassium, has not answered the expecta- 
tions of its first advocate. 2 The well-known action of copaiba and cubebs 
on the mucous surfaces, led Dr. Trideau 3 to try these remedies in croup 
and diphtheria, and his experiments have been still further elaborated by 
Bergeron. 4 Dr. Beverley Robinson 5 has also lately strongly recommended 
the use of cubebs in the catarrhal form of diphtheria. This physician 
lays great stress on the importance of making use of the freshly ground 
powder. In catarrhal cases I have found distinct benefit from the use of 
the perles of copaiba. None of the various drugs just enumerated, how- 
ever, can legitimately lay claim to anything like a certain and specific 
action. 

(3.) The general antiseptics include iron, chlorate of potash, carbolic 
acid, and salicylic acid with its compounds. 6 The value of iron has al- 
ready been explained. Chlorate of potash, so useful in many affections of 
the throat and mouth, has also been largely used in diphtheria. Isambert * 
and Seelio-muller 8 have carefullv studied the effects of this druar, and the 
general weight of evidence is very much in its favor. Ten to twenty 
grains may be given every two or three hours. I have not employed car- 
bolic acid myself as an internal remedy, but the sulpho-carbolates, as re- 
commended by Dr. Sansom, 9 have often proved of service in my hands, 
in the secondary poisoning of diphtheria. In the primary septicaemia, 
these remedies have appeared to me quite useless. Five grains of the 
sulpho-carbolate of soda in a little water may be given to a child of two 

1 Memoirs on Diphtheria, from the writings of Bretonneau, Guersant, Trous- 
senu, Bouchut, Empis, and Daviot. Selected and translated by Robert Hunter Semple, 
M.D., London. 1859, pp. 77-93. 

2 Ozanam : Comptes Rendus de l'Academie des Sciences, 1850. 

3 Trait, de l'Ang. Couen. par le Baume de Cop. et le Poivre Cub. , Paris, 1866. 

4 Diet, de Med. et de Chir. Prat., t. x. p. 361. 

: ' American Journal of Med. Science, 1876, p. 30 et seq. 

,; The sulphites introduced by Polli (Brit. Med. Journ., vol. ii. p. 441, 1867) have 
been strongly recommended by Giacchi and Ferrini (whose papers are referred to in 
the body of the article), but I have not tried them myself. 

1 Etudes Chim. sur l'emploi du Chlor. de Potasse dans les Aff. Couenneuses,. 
Paris. 1856. 

8 L'Union Medicale, 9 juillet. 1878. 

9 The Anfcisept'c Treatment, London, 1871. 



DIPHTHERIA. 119 

years every three or four hours. Salicylic acid has been strongly recom- 
mended by Fontheim, 1 and I have used it myself in three cases with ap- 
parent advantage. The following is the formula which I have employed: 
]J. Acid, salicylic 3 iss. ; spirit, rect. 3 iiss. ; aquam distill, ad 3 vj. M. 
Ft. solutio. One to two teaspoonfuls of this solution maybe given every 
three hours. Great success is claimed by Dr. Hanow, 2 of Erlangen, for 
this remedy administered internally in half-grain doses every hour ; but 
these observations require confirmation. The salicylates of soda and 
potash have also been strongly recommended. I have given the former 
remedy in two cases, but in both instances the disease was too far ad- 
vanced for benefit to result. Salicylate of soda and salicylic acid have 
been recently found useless by Drs. Cadet de Gassecourt and Bergeron 
respectively. 3 

(4.) The use of expectorants has long been more or less in vogue. The 
principal remedies of this kind which have been found useful are senega, 
carbonate of ammonia, and the balsams. Senega was recommended as 
an expectorant by Dr. Archer 4 nearly one hundred years ago. It has 
since been frequently employed in this country, and is highly esteemed 
by Dr. West. 5 A dessert-spoonful of the officinal infusion, sweetened 
with a little syrup, should be given every two hours, but the effect of 
the remedy should be watched, and the quantity reduced if any vomiting 
occur. Carbonate of ammonia (two or three grains) may be given with 
the senega, or it may be administered in water. The balsams of copaiba 
and cubebs, though placed under the list of alleged specifics, probably act 
in a great measure as expectorants. 

Local Treatment. — This has varied greatly at different times, and there 
still exists considerable divergence of opinion as to which method is most 
appropriate. Caustics and astringents, solvents and antiseptics, heat 
and cold, have all been in favor at different times and with different ob- 
servers. 

The use of caustics has, perhaps, been more general than that of any 
other class of local application. Bretonneau 6 strongly recommended a 
mixture of hydrochloric acid and honey, in the proportion of one part of 
the former to three of the latter, as a means of checking the local exu- 
dation. The caustic was to be applied only once in twenty-four or 
thirty hours, and its effects were to be carefully watched. Subsequent 
experience has shown that besides being attended with very considerable 
pain, the use of strong hydrochloric acid has no effect in controlling the 
spread of false membrane. The use of a solution of nitrate of silver, and 
even of the solid stick, at one time met with considerable support, and 
has been recommended by Bretonneau, Guersant, Bouchut, and Trous- 
seau, 7 but it is being gradually abandoned by those who hav.e had expe- 
rience of recent epidemics. The same remark is true of sulphate of cop- 
per and the acid nitrate of mercury, both of which have been recom- 
mended for the local treatment of diphtheria. In fact, the profession 
has given up the use of caustics altogether, being convince! that they 
rather aggravate, than check, the local process. 

1 Journal fur Praktische Chemie, 1875, vol. ii. p. 57. 
" Mediz. Xeuigk., Erlangen, May, 1875. 

3 L'Union Medicale, 9 juillet, 1878. 

4 Op. cit. 

5 Diseases of Infancy and Childhood. Sixth edition, London, 1874. 

6 Memoirs on Diphtheria (New Syd. fc'oc. Trans.), London, 1859. 
' Ibid. 



120 DISEASES OF THE PHARYNX, LARYNX. AND TRACHEA. 

Various astringents, such as tannic acid, powdered alum, or perchloride 
of iron, have been used for many years, and still are largely employed. 
Tannic acid and alum are most conveniently administered by insufflation. 
Their effect is increased, as Dr. Loiseau x has pointed out, by using them 
alternately. Half a grain of tannin with half a grain of starch will be 
found the most convenient strength, whilst alum may be employed in the 
proportion of three-quarters of a grain of the salt to a quarter of a grain 
of starch. Insufflations are recommended to be used (by those who be- 
lieve in their beneficial action) at least every hour or two. Perchloride 
of iron is best employed in the form of the tincture ; it should be freely 
applied every two or three hours. The disease is sometimes checked by 
this class of remedies, but on the other hand it sometimes irritates the 
throat — especially if there is much hyperemia — and frequently increases 
the nausea and dislike to food which are so common. I now seldom use 
these drugs, with the exception of iron, which, when employed as a con- 
stitutional remedy, also acts topically. 

Local agents which act as solve)its have been introduced in modern 
times in diphtheria, with the view of getting rid of the false membrane 
without violence. The chief of these are : lime water, solution of caustic 
potash, chlorate of potash, and lactic acid. Added to pieces of detached 
membrane in a test-tube, each of these substances has certainly the power 
of dissolving them ; and whilst the false membrane is in contact with 
the living tissues, they have a similar, though less active, effect. Lime 
water has been particularly recommended by Steiner, 2 and is certainly 
useful when the false membrane is not very thick. Sanne 3 has recently 
suggested a saccharate of lime, which has the advantage of being a more 
stable compound than lime water. These preparations of lime can be ap- 
plied either in the form of sprays or by means of a camel's-hair pencil. 
Liquor potassa? (one part of the liquor to four parts of water) can also be 
used in the same way. Of all the solvents, however, lactic acid is the 
most reliable. I generally apply it freely with a brush, or by. means of a 
piece of lint attached to a wooden rod; the latter instrument permits of 
very free application. I have never met with the inconvenient results 
from the use of lactic acid which Kiichenmeister 4 has described — viz., 
ulceration of the mucous membrane of the lips and mouth. 

In most cases of diphtheria antiseptics are very useful. The best an- 
tiseptics are carbolic acid, permanganate of potash, chlorinated soda, 
glycerine of borax, chlorate of potash, and hydrate of chloral. Carbolic 
acid may be applied in solution (gr. iii. to 5 j.), or in the form of Glyceri- 
num Acidi Carbolici, B.P., 5 or the Vapor Acidi Carbolici of the Throat 
Hospital Pharmacopoeia may be used. Dr. Massei 6 specially recom- 
mends the use of the alcoholized carbolic acid, the carbolic acid being in 
proportion to the alcohol, as 1 to 3, or 1 to 5, according to the severity of 
the local exudation. Permanganate of potash is most serviceable when 
employed at the strength of gr. v. to 3 j. The best formula for chlori- 
nated soda is: Liquor sodas chloratse 3 iv., aquas f x. Chlorate of potash 

1 Gazette Medicale de Paris, 1862. 

8 Zur Therapie der Diphtherie : Jahrbuch fur Kinderheilkunde, 1870. 

3 Op. cit. p. 429. 

4 Die Behandlung der Diphth. Angina durch Zertaubte Milchsaure, Dresden, 
1870. 

5 Dr. Sansom has, however, shown that the antiseptic qualities of carbolic acid are 
greatly diminished by the addition of glycerine (Op. cit. p. 20 et seq.). 

6 Op. cit. p. 43. 



DIPHTHERIA. 121 

may be given in almost any strength, though gr. xx. to 3 j. is generally 
found sufficient. Hydrate of chloral has also been found very serviceable 
by several practitioners. It was first recommended by Dr. Accetella, 1 and 
subsequently by Dr. Ferrini, 2 of Tunis, and has since been highly extolled 
by Dr. Caesare Ciattagli, 3 of Rome, and Dr. Massei, 4 of Naples. In this 
country it has been employed with great success during the last two 
years by Mr. Hughes Hemming, of Kimbolton, to whom I am indebted 
for its recommendation. Mr. Hemming uses the syrup of chloral (gr. 
xxv. ad 3 j-)? an d directs that it should be employed every hour or two. 
It does not, as a rule, cause any pain, and the nurse can be easily taught 
to apply it. Mr. Hemming observes that, " whilst it rapidly gets rid of 
the fetor, it is beautiful to see the membrane loosen and come away, 
leaving a healthy surface underneath." This remedy has also been very 
successfully used by Mr. Charles Hemming, of Bishop's Waltham. One 
of the solutions above mentioned should be perseveringly employed in 
all cases of diphtheria where there is much false membrane. The antisep- 
tic may be used either as a gargle or a spray; or the patient's mouth may 
be washed out with it by the attendant. In this way the horrible fetor 
of the breath, which is so common in diphtheria, will be prevented. It 
must not, however, be expected that the use of antiseptic solutions will 
have any restraining influence on the exudative process, though it may, 
to some extent, destroy the parasitic fungi so frequently present in the 
exudation. There is also a class of remedies which, though not strictly 
speaking antiseptic, still, by exclusion of air from the false membrane, ap- 
pears to have antiseptic influence. These are, in fact, varnishes, and con- 
sist of gummy matters dissolved in a fluid which evaporates quickly. I have 
tried gum benzoin, gum tolu, mastich, and resin. These substances can 
be dissolved in rectified spirits, or in ether, or a tincture of the gum or 
resin may be mixed with ether. On the whole I prefer the ethereal solu- 
tions (1 in 5), and tolu is most pleasant to the patient, and, lasting longest 
as a varnish, has to be least frequently reapplied. The surface of the 
false membrane should be dried with blotting-paper 5 before the applica- 
tion is made. 

There yet remain two local applications to be considered, viz., ice and 
steam. 

In many cases the patient will derive great comfort from frequently 
taking a piece of ice into his mouth. The annoying dryness and heat of 
the throat, as well as the dysphagia, will be thereby materially alleviated, 
and the inflammation sometimes arrested. The application of ice to the 
neck in a bladder or ice-bag is sometimes agreeable, and probably gene- 
rally beneficial. The use of ice is especially indicated in the first stage of 
the disease, particularly in those cases where there is much inflammatory 
tumefaction. 

On the other hand, heat is a very useful agent when the false mem- 
branes have attained any considerable degree of thickness. Hot fomen- 
tations, applied externally to the throat, are often found to relieve the pain 
in a remarkable way, while the use of steam inhalations appears to exer- 

1 Campania Medica, No. 12, 1873. 

2 Storia Clinica della Difterite osservata nella Citta di Tunisi negli anni 1872-73. 
<Lo Sperimentale, Luglio e Settembre, 1874.) 

3 Gazzetta Medicale de Roma, Maggio, 1876. 

4 Op. cit. 

5 For holding the blotting-paper a miniature paper-clip, which can be fixed at di£ 
ferent angles, is sold by Messrs. Mayer & Meltzer, 71 Great Portland Street. 



122 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

cise an extremely favorable influence on the local process. As a vehicle 
for conveying a volatile medicament, steam has been recommended by 
many physicians, but as a remedy in itself for diphtheria it was first sug- 
gested by Dr. Prosser James. 1 The theory on which it is now used, how- 
ever, is due to Oertel, 8 who has earnestly advocated the employment of 
steam on scientific grounds. When it is found impossible to check the 
formation of lymph by the use of local remedies, the rational treatment 
is to convert, as far as we can, the inflammatory into a suppurative pro- 
cess. Such a transition invariably takes place before the return of nor- 
mal conditions, and to promote this transition is equivalent to hastening 
the restoration of health. Oertel has found that the internal use of moist 
warmth facilitates the occurrence of suppuration more than any other 
agent, and he recommends repeated inhalations of hot vapor. He has 
observed that at the end of from twelve to eighteen hours, during which 
the inhalation has been practised hourly or half-hourly for ten or fifteen 
minutes each time, the margins of the diphtheritic deposits, which previ- 
ously passed imperceptibly into the surrounding tissue, become more 
sharply defined, and contrast strikingly with the intensely reddened mu- 
cous membrane. The patches, therefore, at first sight seem enlarged. 
Besides this, the operation of the hot vapor has been to induce a consid- 
erable excretion of pus corpuscles. If the inhalations be continued, the 
false membranes will be seen to become gradually thicker and raised up 
from the mucous membrane. At the same time they change in color, 
and their surface becomes wrinkled and uneven. After some days they 
are completely detached, and the mucous membrane is healthy, except for 
a variable degree of catarrhal inflammation. The inhalations may be 
made to serve another purpose, viz., that of cleansing and disinfecting the 
mouth, and with this object the Vapor Acidi Carbolici, or Vapor Pini 
Sylvestris (Throat Hosp. Phar.) may be used. 

As young children cannot generally be induced to inhale the steam 
from an inhaler, " a croup-tent " should be erected over the cot for this 
purpose. An excellent portable apparatus 3 has been made for me by 
Messrs. Mayer. When the parts of the tent are put together, and a 
blanket thrown over it, it represents, on a small scale, the upper part of 
an old fashioned four-post bed (with the curtains drawn) such as is still 
common in the country. 

The tent method of administering inhalations has been in vogue at the 
Children's Hospital for many years. 4 The steam-kettle 5 should then be 
placed near the tent, and steam passed within it. 

The detachment of the false membranes, which has by some been ad- 
vocated as a preparatory step to the application of remedies, cannot be 
recommended, except in cases where it may be necessary for the relief of 
urgent dyspnoea, or where putrefying membrane is lying loose in the 



1 Sore Throat. 1861, p. 39. 

- Ziemssen's Cyclopaedia, vol. i. art. Diphtheria, p. GT5. 

3 The " portable croup-tent " consists of eight metal rods. Two of these represent- 
ing the length of the tent are four feet long, and two representing the width are two 
feet six inches long. The four supports are two feet four inches in height. The 
eight pieces screw together, and when separated can easily be carried in the hand. A 
special cloth or blanket, sold with the framework, completes the apparatus. The 
croup-tent is exceedingly useful, not only in cases of diphtheria and true croup, but 
also in laryngitis stridulosa. for saturating the atmosphere with the fumes of nitre and 
stramonium. 

4 Jenner : Op. cit. p. S3. 

6 An excellent steam-kettle is sold by Messrs. Allen, of Marylebone Lane. 



DIPHTHERIA. 12 3 

throat. As a rule, the false membrane, when thus removed, rapidly re- 
appears, and often with increased activity and over a wider area. 

The above are the modes of treatment and kinds of remedies which 
are suitable in different forms of diphtheria. Many others might have 
been enumerated. As in the case of all diseases which are very fatal, a 
vast multitude of remedies have been most enthusiastically recommended, 
but I have referred to those only which I have myself tried. 1 It will per- 
haps give a more precise idea of the management of the disease if we 
suppose a certain typical case before us, and go through the various 
phases of treatment that may be required: 

A child is attacked with a sore throat during an epidemic of diphthe- 
ria, and an examination of the fauces shows that the disease has already 
commenced, thin patches of false membrane being present. The little 
patient should at once be put to bed in a large, well-ventilated room, and 
should be made to suck ice constantly, whilst a bladder of ice should be 
applied to the neck. A simple but highly nourishing diet of beef -tea, eggs, 
etc., should be ordered, and stimulants as a rule be given from the very 
commencement. If there be evidence of primary blood-poisoning, twenty 
to thirty drops of the tincture of perchloride of iron and the same quan- 
tity of glycerine, and five to ten grains of chlorate of potash, in half an 
ounce of water, should be administered every three hours; if, on the 
other hand, the catarrhal symptoms be very marked, the balsamic treat- 
ment should be tried, and a capsule or perle of copaiba containing four 
minims of the balsam should be given ever^ r four or six hours. Local 
solvents should now be employed, and the throat should be sprayed every 
two or three hours with lactic acid solution, or, if the child will not allow 
this to be done, the pharynx must be forcibly swabbed with this remedy ^ 
or the syrup of hydrate of chloral may be applied in the manner already 
advised. If, in spite of this treatment, the disease advances, and the false 
membrane becomes thick and abundant, it should be painted with an 
ethereal solution of tolu (1 in 5), the surface of the false membrane being 
first dried with blotting-paper. . This application, if thoroughly made, 
need not be applied more than once, or at the most twice, a day. Ice 
should now be given up, and warm inhalations, made antiseptic from time 
to time, constantly employed, by means of the croup-tent, in order to 
bring about suppuration and cause the false membrane to separate by the 
normal pathological process. It is useless continuing the copaiba any 
longer, and the iron often appears to lose its effect. It is at this period 
that the sulpho-carbolates sometimes have a wonderfully beneficial effect, 
and at this stage also quinine, in large doses, may be given at the same 
time with advantage. If the disease extend to the larynx or nose, the 
appropriate treatment hereafter detailed should be pursued. The third 
stage being characterized in favorable cases by the natural tendency to 
the separation of false membrane, the hot inhalations must be industri- 
ously continued, whilst the patient's strength is kept up by the use of 
highly nutritive drinks and stimulants. Such is the plan of treatment 
that may be pursued in an ordinary case of diphtheria. Complications, 
of course, require special remedies, and the sequela? need appropriate re- 
storative measures. 

The impaired innervation of the lungs, which proves fatal in so many 
cases of diphtheria, is difficult to cope with. The most reliable measures 



1 Bromine and sulphuret of potassium as general remedies, and chloral hydrate as 
a local antiseptic, are almost the only exceptions to this statement. 



124 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

consist in the assiduous administration of food and stimulants. The in- 
halation of weak ammonia has been recommended to meet this condition. 

During convalescence the patient must still be carefully watched. 
The weakness and anaemia are best treated by iron and other tonics, by 
cod-liver oil, and by residence at some bracing watering-place. These 
measures are also appropriate in cases of muscular paralysis, but they 
then require to be supplemented by other therapeutic measures, according 
to the special symptomatic indication. The slight palsy of the pharynx 
and soft palate, which is the commonest form of post-diphtherial par- 
alysis, generally passes off in a few weeks without treatment. Where, 
however, there is marked loss of power of the pharynx, epiglottis, or 
cesophagus, so that the food is only swallowed with great difficulty, it 
may be necessary to feed by means of the oesophageal tube; indeed, this 
procedure may be absolutely necessary to prevent the patient dying from 
inanition. In less extreme cases the use of the feeding tube will serve 
to prevent the food from passing into the larynx, an accident which is 
likely to be followed by inflammation of the lungs, and is always attended 
with great danger to the life of the patient. Sometimes it is sufficient 
to feed the patient on thickened liquids (see page 86). When the 
paralysis is obstinate, and when it extends to the muscles of locomotion, 
the employment of electricity is indicated. Both the faradic and galvanic 
currents are useful, but they should be applied in a mild form. For the 
extremities, this treatment may be combined with friction and shampooing 
of the affected parts. 

Prophylaxis. — Before concluding the treatment of diphtheria, it may 
be well to add a few words on its prophylaxis. When inspecting the 
patient's fauces, or cleaning or changing the tracheotomy tube, the 
practitioner should be very careful to prevent any of the morbid secretions 
from coming into contact with his lips or mouth, fatal results having 
followed the neglect of this precaution. Like precautions should also be 
impressed upon the attendants who have charge of a case of diphtheria. 
Orders should at the same time be given that no one but the attendants 
should enter the sick-chamber, except upon urgent necessity; and all 
linen, spittoons, or other articles which the patient may have used, should 
be carefully disinfected. By adhering strictly to these rules, it is gen- 
erally possible to prevent the extension of the disease. 



LARYNGOTRACHEAL DIPHTHERIA, FORMERLY CALLED 

CROUP. 

Latin Eq. — Angina trachealis. 

French Eq. — Le Croup. Diphtherie Laryngee. 

German Eq. — Hautige Braune. Croup. 

Italian Eq. — II Croup ; il Crup. Difterite laryngea. 

The term croons, or croup, has been used popularly in Scotland from 
an early period. The word " croops " was first employed by Dr. Patrick 
Blair in 1713, and " croup " by Dr. Home, a little more than a century 
ago. Since then it has been somewhat vaguely used, both by the public 
and the profession in all parts of the world, to describe a certain train of 



LARYNGOTRACHEAL DIPHTHERIA. 125 

laryngeal symptoms. The word is probably derived from the crowing 
breathing, which is such a frequent accompaniment of the disease it was 
intended to describe. It has many allies in other languages, the closest 
being the Dutch Geroop, a cry; but the following are doubtless all 
derived from the same root, viz., Icelandic, Ilrbpa ; Anglo-Saxon, 
Hreopan ; Gothic, Hropjan ; Old German, Hrof ; Modern German, 
Ruf ; all words intended to represent the sound of the voice. 1 The 
Scotch word Roup — hoarseness, has the same derivation. On the other 
hand croup may be derived from the Gaelic crup, signifying ^contraction^ 
i. e., contraction of the throat. 

History (The Relation of Croup to Diphtheria). — Though trfe history 
of diphtheria has been already briefly sketched, it is necessary to make a 
few remarks to explain how a form of diphtheria came to be regarded as 
a distinct disease, and to point out how other laryngeal affections have 
been and still are — at least in this country — included under the name of 
croup. Until diphtheria appeared in England in 1858 the term " croup" 
was employed to describe an acute affection of the larynx, believed to be 
inflammatory and non-contagious, in which false membrane was present. 
The tendency of modern investigation, however, is to show that cases 
formerly described as typical examples of croup were in fact examples 
of isolated laryngeal diphtheria. French physicians, who since the time 
of Bretonneau had been more familiar with diphtheria than the profession 
in this country, almost universally regarded the two affections as identical. 
When the violent epidemic of diphtheria broke out in England, in the 
year 1858, it was natural that practitioners should fail to connect the 
epidemic affection with the typical croup (previously generally isolated 
or endemic) with which they were familiar. Although the antiphlogistic 
theory was on the wane, croup was still described in text-books as a 
disease requiring active and lowering remedies;"' whilst it was soon per- 
ceived that diphtheria could only be combated by analeptic treatment. 
Hence from the very outset an artificial distinction was created in the 
minds of prectitioners. 

Whilst the term croup had been strictly applied to the pellicular 
inflammation of the larynx, many laryngeal affections in which a shrill 
cough, or a crowing inspiration, was present, had been described as vari- 
eties of croup; and the terms " false croup," " spurious croup," " catarrhal 
croup " were in comfnon use. These affections, which are still often mis- 
taken for true croup (see Diagnosis), had still further warped the judg- 
ment of the profession as regards the true nature of laryngeal diphtheria. 
Near the termination of the great epidemic, 1858-62, in this country, the 
identity of the two affections was, however, advocated by the late Dr. 
Hillier, 3 and in my Jacksonian Prize Essay 4 (1863), I maintained the 
same view. The doctrine of identity has subsequently been urged with 



1 Edinburgh Monthly Medical Journal, February, 1856. — Observations on Croup, 
by Charles Wilson. 

' 2 Even Dr. Squire, in his able and comprehensive article published so lately as 18(56 
(Russell Reynolds's System of Medicine, vol. i. p. 234 et seq.), recommends, in certain 
cases, bloodletting to the extent of three or four ounces for a child of four or five 
years of age. 

3 Med. Times and Gaz., April 26, 1862. 

4 This essay is in the library of the Royal College of Surgeons, and an extract from 
it referring to the subject of diphtheria and croup was published in the Brit. Med. 
Journ. , March 5, 1S70. 



126 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

great earnestness and ability by Dr. Semple, 1 and his writings must have 
exercised considerable influence in this country. 2 

The advocates of the duality theory have based their views (1) on 
the supposed pathological differences, and (2) on the alleged clinical 
differences. 

(1.) The supposed pathological differences in the structure of the two 
kinds of false membrane were formerly put forward as matters of great 
importance. Virchow, 3 the originator of these hypothetical distinctions, 
though admitting that the diphtheritic exudation was very similar to that 
of croup, maintained that the former was poured out into the substance 
of the uAicous membrane, while the latter was only a coagulation upon 
its surface. On this hypothesis he founded what was once esteemed a 
most important point in practical diagnosis. The diphtheritic membrane, 
he asserted, could not be removed without tearing away portions of the 
underlying tissues, and leaving a bleeding surface. The croupous pellicle, 
on the other hand, could be easily detached, and the denuded surface 
would be found quite healthy, with the exception, perhaps, of a variable 
degree of hyperemia. Before long, Virchow found himself compelled to 
surrender this distinction, as it was found in practice that the two forms 
of exudation passed into each other by insensible gradations. He now 
changed his ground, 4 and promulgated the view that death (necrosis) of 
the subjacent tissues was the characteristic and essential feature of diph- 
theritic exudation. Practically, however, this distinction was found to 
be no more satisfactory than the former, for cases came under observation 
which clinically answered to croup, but in which there was distinct death 
of tissue. It was also pointed out that the difference in the degree of 
adhesion of the croupous and diphtheritic exudations is due to the differ- 
ence in the structure of the parts on which they are thrown out. The false 
membrane is naturally more closely adherent in the pharynx, where the 
epithelial layers on which it is deposited are not marked off from the 
subjacent tissues b}' any definite homogeneous basement membrane. On 
the other hand, in the larynx and trachea the presence of the basement 
membrane favors the separation of the lymph. It has thus at length 
been generally admitted that there are no sufficient naked-eye appearances 
to distinguish the croupous from the diphtheritic exudation. Xor have 
microscopical observers met with any better success in their endeavors to 
differentiate the two diseases. Dr. E. Wagner, 5 whd has done the best 
work in this direction, has openly declared that his preparations of 
croupous and diphtheritic membranes are very much alike. The diph- 
theritic deposit he describes as a transparent, homogeneous, lustrous 
network, the interspaces of which are, for the most part, filled with lymph 
and pus corpuscles, though some of them are void of contents. The 



1 Croup and Diphtheria, London, 1872. 

2 Most physicians in this country who have had the opportunity of studying the 
disease in the wards and in the deadhouse now regard croup as a form of diphtheria. 
At an early period Dr. George Johnson (Brit. Med. Journ., Feb. 19, 1870) maintained! 
the identity of croup and diphtheria; and. later, our great clinical teacher. Sir William 
Jenner (Lancet, Jan. 2 and 1G, 1875) gave in his adhesion to this doctrine. The 
renowned Traube. of Germany, had previously accepted the unity theory (Berlin : Klin. 
Wochenschrift, No. 31, 1872 . 

:i Archiv, 1847, p. 253 et seq. 

4 Handbuch der Spec. Path. und. Therapie, 1854, vol. i. p. 202. See also Berl. kL 
Wochenschrift, 1665, No. 2. 

5 Archiv. der Heilkuude, I860, vii. p. 481. 



LARYNGOTRACHEAL DIPHTHERIA. 127 

croupous membrane consists of a close network of delicate threads, the 
meshes of which contain numerous elements resembling pus-cells. Wag- 
ner, how T ever, differs from many other observers, holding that the network 
in both cases has its origin in a peculiar fibrinous degeneration of the 
epithelium, and not in the separation of a coagulable fluid from the blood. 
Rindfieisch ] admits that the pathological process in "pharyngeal croup" 
is the same as that which takes place in " laryngeal croup," and thus 
gives in his adhesion to the views maintained in the present article; but 
in spite of their anatomical identity, he feels bound to oppose any clinical 
fusion of the two diseases. 

It will be seen from a consideration of the above facts that the patho- 
logical differentiation of the phenomena must be abandoned. We hence 
come to 

(2.) The clinical differences. The supposed differences are (a) The 
site of the disease; and (b) its manifestations. 

[a) Diphtheria is said to be an affection of the pharynx occasionally 
spreading to the larynx, whilst croup, it is asserted, is essentially a dis- 
ease of the larynx or trachea. The fact is, that croup is a disease which 
commonly commences in the pharynx, and only in about 10 or 12 per 
cent, of cases originates in the larynx or trachea. Difference of site, 
moreover, in a constitutional disease does not constitute a specific differ- 
ence. Cancer is always cancer, whether the pharynx alone, or the larynx 
alone, is affected, or whether the two parts are attacked at the same time 
or consecutively, and rheumatism is still rheumatism, whether it affects 
the heart or the ankle. 

(b) As regards the manifestations of the disease: 

(1) croup is said to be a local disease, (2) to be a sthenic inflammation, 
in which (3) the lymphatic glands are not affected; and (4) in which 
there is no albuminuria, nor (5) paralysis; whilst 

(1) diphtheria is a constitutional disease, (2) of adynamic type, in 
which (3) the cervical glands are inflamed, and (4) in which there is no 
albuminuria (5) nor paralysis. 

To discuss these briefly: 

(1) It is true that in croup the general symptoms are not so severe as 
when the membrane is thrown out on an extensive portion of the pharynx. 
This fact admits of ready explanation, on the view that the septic symp- 
toms are in part secondary to the local processes. For whilst the lym- 
phatics of the mucous membrane of the soft palate, of the tonsils, and of the 
back of the pharynx have very free communications with the numerous 
glands below the angle of the jaw, the absorbent vessels of the mucous 
membrane of the larynx and trachea, are conveyed only to the solitary 
gland just below the greater horn of the hyoid bone, and the small gland 
at the side of the trachea. 2 There is, therefore, much less liability to 
general infection when the local process has seized only on the latter parts. 
When the primary septic poisoning is powerful the constitutional symp- 
toms are, however, as marked in so-called croup as in diphtheria. 

(2) Cases of sthenic croup are very rarely met with, and the same re- 
mark applies to diphtheria. On the other hand, there are medical men 
who assert that bleeding can be employed in diphtheria with success. 3 

1 Lehrbuch der Pathologischen Gewebelehre, Third edition, pp. 311-12. 
- Luschka : Der Schlundkopf des Menschen, Tubingen, 1871, p. 150. 
3 Courier Medical, Sept. 7, 1878. Dr. Simorre reports fifty-three cases of diphtheria 
treated by bleeding ! All the patients recovered — most of them in twenty-four hours. 



128 

Hence distinctions based on differences of type in the two diseases can 
have no weijrht. 

(3) The cervical glands are not often affected in croup, because the 
mucous membrane of the larynx has no communication with the superfi- 
cial cervical glands; on the other hand, as stated above, there is an 
elaborate connection between the pharynx and the lymphatic glands. 

[In cancer of the pharynx also the cervical glands are always en- 
larged, whilst in cancer of the larynx the glands are seldom at all af- 
fected.] 

(1) In croup albuminuria is often present. 

(5) Paralysis is rare in croup, because nearly all the cases terminate 
fatally, but it is occasionally met with in those that survive. 

I have entered into these details because details must always have a 
certain amount of significance; but it is more satisfactory to look at the 
question from a broad and philosophical point of view. Classifications 
are, after all, mere arbitrary arrangements by which knowledge may be 
placed in an accessible form for further use. The oldest classifications 
are purely symptomatic. When anatomy came to be mastered we had 
an anatomical basis for classification, and we are still obliged to make a 
considerable use of this system: but, as medical science progresses, the 
disposition is to track disease to its origin, and seek out its hidden causes. 
Hence we see arising at the present day an etiological classification. The 
cause of disease, when it can be discovered, is now regarded as the essence 
of its specific nature. The ordinary inflammation of mucous membranes 
is attended with engorgement of the tissues, and the formation of pus on 
the surface; under the influence, however, of a certain poisonous conta- 
gium the inflammation, instead of being attended with the formation of 
pus, leads to the exudation of layers of lymph, which become adherent 
to the free surface of the mucous membrane. This disease is called 
"diphtheria," and whether the lymph is deposited on the mucous mem- 
brane of the pharynx, or larynx, or trachea, or bronchial tubes, or any 
other mucous membrane, or on a wounded surface, the disease is still 
" diphtheria." To suppose that there are two kinds of pellicular inflam- 
mation of the larynx, one in which the cause is the diphtheritic poison, 
and the other in which the cause is some other undiscovered influence, is 
totally opposed to all probabilities. 

Etiology. — This has already been discussed under diphtheria. 

Symptoms. — The disease develops in three different ways. It may 
originate in the larynx. This is typical croup, and probably does not occur 
in more than 10 or 12 per cent, of cases. 1 Most commonly it commences 
in the pharynx, and extends downward, constituting descending croup. 
Occasionally, but very rarely, it commences in the bronchial tubes or 
trachea, and ascends into the larynx. This is ascending croup. If, as is 
commonly the case, the disease commences in the pharynx, the practi- 
tioner will be constantly on the watch to note the first invasion of the 
larynx, but in typical croup, or primary laryngeal diphtheria, it is other- 
wise, and the symptoms of croup have been conveniently divided into 
three stages. 

Thejirst stage is often preceded by slight catarrh. So insidious «is the 
invasion of the disease that the serious character of the child's illness is 



1 See Sanne : Op. cit. p. 195- Sanne gives 142 cases out of 1,172. Compare also 
Simon : Nouveau Diet, de Med. et de Chir. Prat. 



LARYNGOTRACHEAL DIPHTHERIA. 129 

often quite unsuspected. The little patient is noticed to be languid and 
feverish, he is thirsty, and refuses food, and at the same time there is 
slight hoarseness, which the nurse attributes to an ordinary cold, until her 
apprehensions are aroused by a frequent, short, dry, shrill cough. The 
voice, which was at first only a little harsh, very quickly loses its resonant 
character and becomes a whisper. On examining the chest, both the in- 
spiratory and expiratory sounds are found to be prolonged, and the nor- 
mal respiratory murmur is lost in the laryngeal stridor which occurs in 
inspiration. The supraclavicular spaces are usually somewhat more de- 
pressed during inspiration than in the condition of health, and the slight 
difficulty of breathing which is present is more marked during sleep. 
The pulse now becomes considerably increased in frequency, and the fe- 
brile symptoms generally more pronounced. If a laryngoscopic examina- 
tion can be accomplished, the mucous membrane of the larynx is seen to 
be of a bright red color, and when the disease has existed for a few hours 
some thin patches of false membrane may be perceived on the mucous 
membrane of the larynx. The usually pendent position of the epiglottis 
in children often prevents a satisfactory examination even in those of 
tractable disposition; but the timidity of early life is in itself often suffi- 
cient to render the employment of the laryngoscope impossible. It is 
most important at this stage of the disease to make a very careful exam- 
ination of the sputa. Children very often do not expectorate at all, but 
anything that is brought up must be put into a glass vessel and gently 
shaken with a little pure w r ater. The mucus dissolves, and flocculi or 
small shreds of false membrane, if present, become visible. 

Ihe second stage is characterized by increasing dyspnoea, and by the 
attacks of suffocation which suddenly supervene from time to time. When 
the attack comes on the child is generally found sitting up in bed, with 
red and swollen face, and an anxious, terrified look. The nostrils are 
rapidly w T orkiag, inspiration is hurried and " croupy," and is evidently 
performed with the greatest difficulty, all the auxiliary muscles of inspi- 
ration being called into play. The voice is almost inaudible, and there is 
a constant hoarse and stifled cough, without expectoration. The attack 
generally lasts three or four minutes, and the patient subsides into a 
heavy sleep which often continues for several hours. Sometimes unmis- 
takable pieces of membrane are thrown up with the cough, a phenomenon 
which is often most important as a means of diagnosis, as in many chil- 
dren suffering from laryngeal diphtheria there are no patches of exudation 
to be detected on a casual inspection of the fauces. It is only on care p ul 
and persevering examination with the laryngoscope in cases favorable 
for examination that the membrane, which is the source of all the trouble, 
can sometimes be recognized adhering to, or perhaps lying loose in the 
chink of the glottis, and obstructing the passage of air. Occasionally 
the vomiting, which is induced by the constant fits of coughing, or by the 
administration of emetics, may lead to the separation and ejection of 
large pieces of membrane, in which case the urgent symptoms of dyspnoea 
are often most strikingly relieved. The mode in which separation takes 
place is exactly the same in the larynx and trachea as in the pharyngeal 
region; the process*, however, is rendered easier by the arrangement of 
the mucous membrane, which, in the trachea and in the lower parts of the 
larynx is separated from the submucous tissues by a distinct basement mem- 
brane. But the improvement due to the expulsion of the concretions is 
generally only temporary; exudation again collects, and the symptoms 
return in greater intensity than before. At this stage of the disease the 
Q 



130 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

pulse is very rapid, and generally irregular. The little patient is ex- 
hausted and is constantly bathed in sweat. 

The third stage now supervenes. As the disease advances the suffo- 
cation becomes more urgent, and there is no remission between the at- 
tacks^ the dyspnoea being constant, though fearfully aggravated everv 
few minutes. The lips assume a livid color, and the nails become blue. 
The sternum and the intercostal spaces are forcibly drawn inward during 
each effort at inspiration, whilst the agony of impending suffocation is 
most distressing to witness. The child throws his arms wildly about, or 
clutches his throat to tear away, as it were, the obstruction, or he thrusts 
his fingers into his mouth to seize the offending substance. The symp- 
toms of fever are intensified, the thirst is urgent, the tongue thickly 
furred, and the pulse quicker but weaker. The little patient dies in an 
attack of dyspnoea or soon succumbs to gradually increasing coma, to syn- 
cope, or exhaustion. 

Diagnosis. — In children it is sometimes very difficult to distinguish 
catarrhal laryngitis, of a severe form, from croup. Indeed in the early 
stages it is often impossible to differentiate the two affections. In young 
children, from the small size of the larynx, and the great tendency to re- 
flex irritation, slight inflammation of the larynx quickly gives rise to 
spasm, and produces stridulous breathing, laryngitis strididosa, as it is 
technically called. When, however, the disease is fully developed, the 
two affections are easily distinguished, for whilst catarrhal laryngitis 
nearly always ends in recovery, in diphtheria the prospect of a fatal ter- 
mination is soon apparent. Croup very often commences at night, but 
catarrhal laryngitis almost invariably comes on at that time ; hence we 
have in the time at which the disease first manifests itself a possible diag- 
nostic sign. It has already been pointed out that the laryngoscope can- 
not ften be successfully used in young children, but the expectoration 
must be examined in the way already described, and false membrane, if 
present, will always be detected. 

Further, there is a pure neurosis, a spasmodic action of the adductors 
of the vocal cords, giving rise to laryngismus stridulus, which has beer 
called "spurious croup," " false croup," and "nervous croup," with which 
true croup is sometimes confounded. This disease very frequently comes 
whilst the mother is suckling, or dandling the child. Carpo- pedal con- 
tractions also occur in marked cases of laryngismus, but above all there is 
the absolute intermission of all dyspnoea between the paroxysms ; whilst 
in true croup, when fully established, slight dyspnoea is always present 
between the attacks of suffocation. Many fatal cases of laryngismus, 
however, no doubt lose their qualitative affix and appear in the Mortality 
Returns as simple " croup." ' 

Pathology. — The false membrane does not differ essentially from that 
described in connection with the pharyngeal form of the disease. The 
membranous exudation is more frequently found on the epiglottis and 
the ary-epiglottic folds than on the lower portions of the larynx, but oc- 
casionally it invests the whole of the lining membrane of the larynx, ex- 
tends throughout the ventricles, and passes along the trachea to the 
smallest ramifications of the bronchi. It rarely happens that the lymph 
is so abundant as to completely occlude the larynx, and in many fatal 
cases only a very thin, transparent membrane is found. The dyspnoea in 



1 The above considerations tend to show that the substantive use of the word 
" croup " is altogether objectionable. 



LARYNGOTRACHEAL DIPHTHERIA. 131 

croup is primarily due to the inflammatory tumefaction and plastic exu- 
dation, which, however, soon gives rise to spasm of the adductors. The 
muscles are infiltrated with serum, but there is no paralysis of the abduc- 
tors, nor atrophy of their structure. 1 The lymph is also more closely ad- 
herent in the supra-glottic than in the sub-glottic region. On removing 
the lymph the mucous membrane is generally almost normal below the 
level of the vocal cords, but above that line it is often swollen and in- 
flamed, and sometimes ulcerated. It has already been stated that the 
membrane which forms in the trachea can be much more easily detached 
than that which is found in the pharynx. There is nothing special as 
regards the false membrane in the trachea, which is generally more ad- 
herent in the upper than in the lower portion of the tube. 

Prognosis. — The prognosis is most unfavorable. Probably not more 
than ten per cent, of the patients recover under suitable treatment with- 
out tracheotomy. In this country tracheotomy is, comparatively, so little 
practised in croup — in proportion to the number of cases — that nearly all 
the remainder prove fatal. If, however, the remaining 90 per cent, were 
tracheotomized, 66 per cent, might recover according to the most favora- 
ble statistics (see note 3, page 184), or, according to an average, based on 
4,663 operated on in the Children's Hospitals of Paris, 23.91 per cent. 
Accepting the latter figures, out of 100 cases of undoubted croup we 
might expect that 68.49 would terminate fatally, and 31.51 recover — 10 
without tracheotomy and 21*51 (L e., 23.91 per cent.) after the operation. 
If the trachea were not opened in the proper proportion of cases the fa- 
tality would, of course, be proportionately greater ; whilst if the opera- 
tion were performed earlier than is commonly the case, the mortality 
would "probably be considerably less. The fatal termination may be ex- 
pected in the first three or four days, certainly within the first week. 

Treatment: First Stage. — The child should be placed in a warm, 
well-ventilated room, an ice-bag should be applied to the neck, and ice 
constantly sucked. Spray inhalations of lactic acid (TT[, xx. ad |j.) 
should be employed. The inhalations should be given at least every 
hour, and continued for five minutes at a time. In the second stage, or 
as soon as it is believed that false membrane has formed, emetics must be 
employed. A number of instances are recorded in which children have 
been saved from imminent asphyxia by the spontaneous expulsion of false 
membrane, and this natural mode of cure has sometimes been happily 
imitated by the administration of emetics. According to Valleix, 2 in 
thirty-one cases so treated, fifteen recovered, whilst of twenty-two in 
which this class of remedies was neglected, only one cure resulted. 
Trousseau concurs with the statements of Valleix. In many cases, how- 
ever, the relief is merely temporary, the membranes quickly reforming in 
the larynx, and the dangerous symptoms returning with increased severi- 
ty. Moreover, the practice is not altogether unattended by danger, for, 
the tracheal membrane may be forced up by the act of vomiting in such 
a way as to entirely obstruct the passage of air. This risk must be in- 
curred, though valuable time should never be wasted on the use of emetics, 
when the only alternative is the performance of tracheotomy. Tickling the 
fauces will occasionally be sufficient to excite the desired action, but as a 
rule, it is necessary to resort to drugs. Cardiac depression is so common 

1 See an interesting case recently published by Dr. Baginsky : Central. Zeitung f iir 
Kinderheilkunde, October 1, 1878. 

v Guide du Mud. Prat., t. i., Art. Diph thorite. 



132 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

an accompaniment of diphtheria that it is unwise to employ any emetic 
by which it is likely to be increased. Tartar emetic must, therefore, be 
especially avoided. Strange as it may seem, this drug has in times past 
been very widely employed in diphtheria. v Trousseau, 1 indeed, strongly 
condemned its use, terming it the most dangerous of all emetics. But 
Bouchut, 2 as late as 1859, published three cases in which he attributed a 
successful issue to the energetic employment of tartar emetic. His ex- 
ample should not be followed, especially as we have at our command em- 
etics which are not less certain in their action than antimony. Should 
the practitioner distrust the efficacy of ipecacuanha, it is quite open to 
him to add from fifteen to twenty grains of sulphate of zinc. If the ad- 
ministration of these agents is not quickly followed by vomiting and the 
expulsion of the membrane it is useless to repeat them, and even where 
the breathing lias once been temporarily relieved by their use, it is very 
questionable whether they should be again employed. In no case should 
the physician place too much reliance upon them. 

When it is judged that there is false membrane loose in the larynx, 
the removal of the membrane by direct mechanical means should be at- 
tempted. The best instrument used for this purpose is a brush attached 
to a piece of soft aluminium wire. Instead of the common laryngeal 
brush I use one made of squirrel's tail. The hairs cover the sides of the 
laryngeal portion of the brush, and are directed upward. As the laryn- 
goscope cannot generally be used, the brush, guided by the forefinger of 
the left hand, should be carried down into the interior of the larynx. 
The windpipe can generally be freed from exudation by to-and-fro move- 
ments combined with a certain amount of rotation. I have several times 
employed this brush with marked advantage. Even if the practitioner 
is successful, however, in detaching portions of membrane, fresh exuda- 
tion often recurs. 

I must here briefly refer to the subject of catheterism and " tubage " 
of the larynx. Catheterism was first recommended by Loiseau, 3 as a 
means of removing false membrane and introducing remedies into the 
windpipe. I have only to say that the false membrane can be much more 
easily removed with a proper croup-brush, and that solutions or powders 
can be more readily applied with a common laryngeal brush or insufflator. 
" Tubage," introduced by Bouchut, 4 consists in the introduction of a small 
tube, from three-quarters of an inch to an inch in length, and leaving it 
in the larynx. It causes so much irritation that it cannot be retained, and 
its use has been quite given up. 

It is at the close of the second stage of croup, when inhalations and 
emetics have failed, that tracheotomy is called for. Marked recession of 
the sternum and chest-walls is the indication for its performance. The 
credit of having been the first to establish this operation on a secure 
basis as a justifiable part of the treatment of croup is due to Bretonneau, 6 
who published his first successful case in July, 1825. Ten years later 
Trousseau 6 reported that he had performed the operation thirty-six times 
with nine recoveries. From this time the position of the operation was 
secured, and it has since been performed many thousand times in France 
alone. Before his death, Trousseau 7 published a series of» -1GG cases in 
which the operation had been performed in the Children's Hospital in 

1 Trousseau : Op. cit vol. ii. p. 578. a L'Union Mt'dicale, April 5, 1859. 

3 Bull, de l'Acad. de Med., 1857. 4 Ibid , Sept., 1858. 

5 Bretonneau : Memoirs (Xew Syd. Soc.). p. 59. 6 Trousseau : Ibid. p. 243. 

1 Trousseau : Rapport a l'Acad. de Med : Bull, de l'Acad. de Med., vol. xxiv. p. 112. 



LARYNGOTRACHEAL DIPHTHERIA. 



183 



Paris, between the years 1849 and 1858. Of these, in spite of unfavora- 
ble surroundings, 126, or more than 1 in 4, recovered. Later statistics 
have given still more favorable results. In 18G3, Fischer and Bricheteau l 
collected all the facts within their knowledge at the Hopital des Enfants 
Malades, the Hopital Sainte Eugenie, and in the city and the provinces, 
and the general results were as follows: — At the Hopital des Enfants 
Malades the operation had been performed in 1,011 cases, and the pro- 
portion of recoveries was 1 in 4; at the Hopital Sainte Eugenie the pro- 
portion was 1 in 6; while the facts collected from other sources, though 
confessedly incomplete, showed in Paris 1 cure to 2.G cases, and 1 to 
3.6 in the provinces. According to M. Sanne, however, who has pub- 
lished the most extensive statistics from the Paris hospitals, during recent 
years the proportion of recoveries after tracheotomy has been less favor- 
able, especially at the Hopital Sainte Eugenie, as will be seen from the 
appended tables 2 : — 

HOPITAL SAINTE EUGENIE. 



Operations for Croup. 



1854 
1855, 
1856. 
1857. 
1858. 
1859. 
1860. 
1861. 
1862. 
1863. 
1864. 
1865. 
1866. 
L867. 
1868. 
18G9. 
1870. 
1871. 
1872. 
1873. 
1874. 
1875. 



Years. 



Dis- 
charged 
cured. 



Dead. 



Left 
uncured. 



Total. 



Proportion of 

cures. 



2 


7 





9 


4 


9 





13 


5 


19 





24 I 


5 


24 


1 


30 j 


23 


95 


4 


122 


17 


88 


4 


109 


7 


31 


2 


40 


16 


45 


3 


64 


23 


67 


7 


97 


35 


68 


3 


106 


26 


85 


4 


115 


44 


87 


G 


137 


36 


76 


3 


115 


29 


63 


4 


96 


SI 


101 


3 


135 


31 


70 


2 


103 


42 


85 


4 


131 


12 


78 


3 


93 


39 


138 


10 


187 


32 


170 


11 


213 


23 


132 


7 


162 


27 


175 


9 


211 


509 


1,713 


90 


2,312 



4.50 
3.25 
4.80 
6.00 
5.29 
6.41 
5.71 
4.00 
4.21 
3.02 
4.42 
3.11 
3.19 
3.31 
4.35 
3.35 
3.11 
7.75 
4.79 
6.65 
7.04 
6.48 



1 in 4.54 



1 Nouveau Dictionnaire de Medecine et Chirurgie, 1869, vol. x. p. 368. 

2 The results at this hospital for the first nine months of 187G were still more un- 
favorable, the proportion of cures being- only 1 in 8.31. This steady increase in the 
mortality after tracheotomy is attributed by M. Moizard (These de Paris, 1876. No. 493), 
partly to the progressive extension of the operation to more and more hopeless cases, 
and partly to the more malignant character of the disease in Paris during recent years. 



134 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 
HOPITAL DES ENFANTS MALADES. 





Operations 


for Croup. 




Years. 


Dis- 
charged 
cured. 








Proportion of 




Dead. 


Left 
uncured. 


Total. 


cures. 


1851 


14 


17 





31 


1 in 2.21 


1852 


18 


43 





61 


1 " 3.38 


1853 


9 


52 





61 


1 " 6.77 


1854 


14 


29 





43 


1 " 3.07 


1855 


12 


34 





46 


1 " 3.83 


1856 


16 


33 


3 


52 


1 " 3.25 


1857 


16 


54 





70 


1 " 4.37 


1858 


34 


73 


2 


109 


1 " 3.20 


1859 


41 


115 


4 


160 


1 " 3.90 


1860 


24 


101 


3 


128 


1 " 5.30 


1861 


29 


72 


1 


102 


1 " 3.49 


1862 


27 


112 


6 


145 


1 " 5.37 


1863 


46 


86 


10 


142 


1 " 3.08 


1864 


40 


105 


8 


153 


1 " 3.82 


1865 


40 


86 


4 


130 


1 " 3.25 


1866 


27 


71 


3 


101 


1 " 3.74 


1867... 


15 


51 


4 


76 


1 " 5.06 


1868 


26 


36 





62 


1 " 2.38 


1869 


12 
21 


54 
43 






66 
64 


1 " 5.50 


1870 


1 " 3.04 


1871 


16 


27 





43 


1 " 2.67 


1872 


30 


71 


9 


110 


1 " 3.66 


1873 


26 


79 


2 


107 


1 " 4.11 


1874 


23 


81 


4 


108 


1 " 4.69 


1875 


38 


130 


13 


181 


1 " 4.TU 




614 


1,661 


76 


2,351 


1 in 3.82 



At the Hospital for Sick Children in the twelve years 1864 to 1876, 
sixty cases of croup and diphtheria were operated on. Of these thirteen, 
or 21.6 percent., were successful. According to Kronlein's ' recent statis- 
tics at the Hospital in Berlin the percentage of cures after the operation 
was 30. 2 This was the result of 567 operations performed between Jan- 
uary 1, 1870, and July 30, 1876, in Professor Langenbeck's Hinic. By se- 
lecting the best individual series of statistics, for the most part from pri- 
vate practice, Dr. Solis Cohen 3 has brought together 166 cases of trache- 
otomy in croup with 110 recoveries ! 

Considering the enormous mortality of laryngeal diphtheria, even the 
most unfavorable figures prove that in such cases tracheotomy is not only 
justifiable, but that it is a positive duty. The chief questions to be con- 



1 Langrenbeck Archiv., Bd. xxi. hft. ii. 

2 See also Hi.ter: Laryngotornie und Tracheotomie, Pitha-Billroth's Chirurgie, vol. 
iii. part, i Nro. •">. p. 26 et seq. 

3 Cr.oup in its Relation to Tracheotomy, Philadelphia, 1874. 



LARYNGOTRACHEAL DIPHTHERIA. 135 

sidered in connection with the operation are what are the indications, and 
what is the best period for its performance ? 

The cases most favorable for the operation are those in which the 
symptoms of general infection are slight or absent, and the strength of 
the patient is unimpaired. It is where the patient has still some vigor, 
where the pulse is strong and regular, the powers of assimilation good, 
and the asphyxia, though very marked, is not yet too advanced, that 
tracheotomy becomes most imperative. In such cases there can be no 
doubt that the operation has saved, and doubtless will still save, many 
thousands of lives. It is now generally admitted that tracheotomy should 
be performed without delay, as soon as it has become clear that it is im- 
possible to relieve the asphyxia by other means. It is clear that an early 
insertion of the canula gives the patient a much better chance of recovery 
than when there is a long delav; and it is owing to the disregard of this 
fact that tracheotomy in diphtheria has in some quarters acquired such an 
evil repute. For the description of the operation, and the precautions 
which must be taken in performing it, I must refer the reader to the ar- 
ticle on Tracheotomy, but I would here call attention to the extreme im- 
portance of endeavoring, immediately after the operation, to draw out 
any loose false membrane, either with the croup-brush, or an aspirator 
accurately applied to the mouth of the canula. The after-treatment is 
very important, and the patient requires most assiduous attention for 
some days. The temperature and due moisture of the room must be care- 
fully maintained, the tube must be constantly watched, and freed from 
secretions or pieces of ejected membrane, and the wound must receive 
daily attention. At the same time the administration of food and stimu- 
lants must be the subject of the greatest care and regularity, and the an- 
tiseptic sprays should be administered through the canula. The chief 
dangers to be feared in the after-treatment of tracheotomy are extension 
of the exudation into the bronchi, occlusion of the tube, and failure in the 
innervation of the lungs. The effects of extension of the membrane may 
in some cases be averted by removing the tube, and extracting fragments 
of lymph from the trachea with forceps, or with the croup-brush. Long 
strips of exudation, and in rare cases almost entire casts of the windpipe, 
have been removed in this way. Occlusion of the tube is only to be pre- 
vented by placing the patient under the charge of a trustworthy attend- 
ant, who will not fail in cases of emergency to remove the canula and free 
the passage. 

In the third stage tracheotomy remains the only hope of saving the 
patient's life. If the operation has unfortunately not been performed 
in the second stage, the chance of success is very much diminished. The 
operation is not contra-indicated, however, even when the apnoea is ex- 
treme, and the patient is apparently on the point of suffocation, provided 
only that the heart's power is still good. In some cases the patient has 
been saved by it when literally at the last gasp. Such instances, how- 
ever, are quite exceptional. Some authorities have maintained that even 
in quite hopeless cases, where the patient is dying from dyspnoea, trache- 
otomy should be performed with the view of promoting the euthanasia. 
It is true that death from syncope or gradjial exhaustion is much less 
painful than death from apncea, and it may be advisable to secure this 
substitution by a surgical operation. But it is not in these cases that 
tracheotomy finds its really valuable application. When it is found, on 
auscultation, that air enters one lung and does not penetrate the other, 
it is clear that the false membrane has extended down one bronchus, and 



136 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

tracheotomy is then much less likely to be of any use. In the same way, 
if extensive pneumonia has supervened the operation is likelv to be of 
little benefit. Where the patient is already dying of cardiac failure or 
exhaustion, it is of course in vain to attempt to save life by the surgical 
operation. * 



NASAL DIPHTHERIA. 

In some epidemics of diphtheria the disease commences with nasal 
catarrh, and this phenomenon was so common in the epidemics witnessed 
by Bretonneau, that he regarded it as the common course of the disease. 
Further experience, however, has demonstrated that catarrh of the nose 
is far less usual than it was at one time supposed, and that true nasal 
diphtheria is generally due to the extension of the plastic inflammation 
from the pharynx. The disease commonly first shows its presence by an 
unhealthy brown ichorous discharge, which causes abrasion, and even 
ulceration, of the skin in the neighborhood of the nostrils. Soon after- 
ward the parts are covered with false membrane which can be seen ex- 
tending through the nose. At other times the false membranes do not 
reach the external orifice, but, on using the speculum, a few scattered 
deposits of lymph can be perceived on the mucous membrane of the 
septum or the turbinated bones. The false membrane, however, is gen- 
erally most abundant at the posterior nasal orifices. 

In this form of diphtheria it is especially necessary to endeavor to 
prevent the products of the disease from accumulating and putrefying in 
the nasal cavities, for experience has shown that, under such circum- 
stances, they are extremely liable to be absorbed and to lead to secondary 
septic poisoning. It is all-important, therefore, to keep the passages as 
clear as possible, by the use of astringent or solvent liquids. With this 
object, weak solutions of alum, tannin, carbolic acid, permanganate of 
potash, or lactic acid, should be repeatedly syringed over the affected 
parts. If epistaxis occurs, as it frequently does in nasal diphtheria, an 
astringent snuff or lotion is usually sufficient to arrest it. Plugging the 
nares should, if possible, be avoided. 1 



THE THROAT AFFECTIONS OF THE ERUPTIVE FEVERS. 8 
(Scarlatina, Measles, and Small-Pox.) 

Latin Eq. — Morbi gutturis inter exanthemata (Febrem rubram; Morbillos, 

Variolam). 
French Eq. — Maladies de la gorge dans les fievres eruptives (Scarlatine, 

Rougeole, Variole). 
German Eq. — Die symptomatischen Halsaffectionen bei den acuten 

Exanthemen (ScharlachfTeber, Masern, Blattern). 



various features of diphtheria are discussed in slightly greater detail in my 
ork, entitled, Diphtheria : its Nature and Treatment. Churchill. 1878. 



'The 
recent work, 

"-' As the pharynx and" larynx are so frequently affected together in the acute ex« 
anthemata, I have thought it better to treat all the local manifestations in this sect ; on. 



THE THROAT AFFECTIONS OF THE ERUPTIVE FEVERS. 137 

Italian Eq. — Le malattie della gola negli esantemi (Febbre scarlatina, 
Rosolia, Vajuolo). 

Definition. — Morbid phenomena manifested in the mucous membrane 
and subjacent structures of the pharynx and larynx during the course of 
scarlatina, measles, and small-pox. 



Scarlet Fever. 

The mucous membrane of the pharynx is generally affected in scarla- 
tina, and in some cases the pharyngeal enanthem appears to constitute 
the only local expression of the disease. Although the skin eruption of 
this fever often conies out on the second day, that is, the day after chilli- 
ness, vomiting, and headache have occurred, in most cases soreness of 
the throat is the first symptom complained of. 

In Scarlatina Simplex little or no redness can be seen on examination, 
and there is only slight aching or stiffness, which ceases in a day or two 
from the commencement of the attack. 

In Scarlatina Anginosa great soreness of the throat is a marked 
feature of the disease. On inspecting the pharynx the whole of the 
mucous membrane is seen to be of a deep red or even violet hue, and as 
the fever develops considerable internal and external tumefaction of the 
tissues takes place. The tonsils, and the submaxillary and parotid glands, 
are implicated in the morbid process, and in many cases all the structures 
of the neck become the seat of a violent phlegmonous inflammation, 
terminating at one or more parts in abscess. At this stage of the malady, 
viz., the third or fourth day of the attack, the mucous membrane of the 
pharynx generally becomes covered with a quantity of whitish pultaceous 
-exudation. The subjacent epithelium is often partially destroyed, giving 
rise to shallow abrasions ; but deep ulceration is very seldom present. 
In some cases resolution takes place at this stage ; the swelling becomes 
reduced, and the tissues soon regain their normal condition. In the worst 
instances, however, suppuration occurs in the cellular tissue or glands of 
the neck, and large abscesses form, which usually burst externally, near 
the angle of the jaw, though sometimes they burrow downward as far 
as the clavicle. After all the specific symptoms of the fever have dis- 
appeared, such cases frequently prove fatal from the exhaustion caused 
by copious and long-continued discharge of pus. During the progress 
of this form of scarlet fever the disease sometimes extends to the larynx, 
when the voice is modified, and, if the epiglottis is much inflamed, de- 
glutition becomes difficult, and liquids regurgitate through the nose. 
Some difficulty of breathing may also be present, but as Trousseau l 
observes, "scarlatina does not like the larynx," and suffocation from 
oedema of the glottis is a rare issue of the complaint. 

In Scarlatina Maligna the characteristic phenomenon is secondary 
diphtheria.'-' In these cases the pharyngeal lesion is more tardy in its 
appearance, and the patient often seems at first to suffer from a mild 
attack of the malady. About the ninth day, when the eruption has 
•disappeared and the feverish symptoms have abated, the disease attacks 



^Clin. Med. de l'Hotel-Dieu. Paris, 1805. vol. i. p. 105. 

- See Fuchs : Historiftche Untersuchungen iiber Angina Maligna und ihr Verhalt- 
oiss zu Seharlachneber und (roup, Wurzbuijr, 182b. 



138 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

the pharynx, and in a few hours swelling takes place in the glands at the 
angle of the jaw. The tonsils and fauces are covered with diphtheritic 
exudation, a fetid sanious discharge proceeds from the nares, and the 
breath becomes tainted with a foul odor. Occasionally the morbid process 
extends to the larynx, and this has been noticed to occur more frequently 
in some epidemics than in others. Gupp ' described an epidemic io 
\Vurtemberg in which, in the greater number of cases, croupy symptoms 
appeared from the third to the fourth day of the illness; and in some cases 
death took place before the exanthem appeared. As in primary diph- 
theria, on separation of the lymph, ulceration of the mucous membrane 
is often found. A characteristic specimen of ulceration (Xo. 3G, Series 
W.) is contained in the Museum of St. Thomas's Hospital. The larynx r 
which was taken from an adult patient who died of scarlatina, has a very 
thin layer of lymph covering the entire mucous membrane, and the right 
arytenoid cartilage is laid bare by a large ulcer. Gangrene not unfre- 
quently attacks the pharynx, larynx, and oesophagus, the pulse becomes 
weak, the surface of the body is blanched and cold, collapse supervenes, 
and the patient dies in a state of coma. 2 In some cases large vessels are 
opened by the ulcerative process, and death occurs from hemorrhage. A 
somewhat rare complication of the malignant form of scarlet fever, 
" scarlatinal buboes," requires some mention. They are situated princi- 
pally in the glands of the neck, which become suddenly inflamed about 
the tenth or twelfth day, and in five or six days a large abscess is formed. 
Sphacelus of the surrounding cellular tissue may take place, and Graves* 
and Trousseau 4 report cases in which the muscles of the neck were laid 
bare, and the carotids could be seen pulsating at the bottom of the wound. 

Diagnosis. — The recognition of the scarlatinal nature of the angina 
is principally based on the existence of the skin eruption during some 
period of the illness. The suddenness of the attack, the intensity of the 
accompanying fever, the deep red or violet tinge of the pharynx, and the 
occurrence at the same time of an epidemic of scarlet fever, all tend to 
assist in the diagnosis; but when the pathognomonic exanthem is absent 
some uncertainty must often remain as to the true nature of the malady. 
In such cases the subsequent development of dropsy and albuminuria oc- 
casionally sets any doubt at rest. 

Prognosis. — The local affection is itself often a cause of death, and as 
the throat manifestations of scarlet fever are the expression of the inten- 
sity of the general blood-poisoning, they furnish an important indication 
as regards the constitutional condition. In scarlatina simplex the local 
affection is unattended with danger. Scarlatina anginosa probably results 
in death in about one-fourth of the persons attacked, whilst in the diph- 
theritic form about half the patients die. 5 

Treatment. — Local measures are of but little use in the treatment of 
the anginas of scarlet fever. Trousseau 6 advises the application of hydro- 
chloric acid to the throat, when it presents a pultaceous or gangrenous 
aspect. The dilute acid has also been administered internally, on the 
supposition of its possessing a specific action against the general blood- 
poisoning. In severe cases a general tonic and analeptic treatment must 
be adopted, whilst emollient gargles, hot, soothing inhalations, and 

1 Ruble : Op. cit. p. 243. 

■ See Graves : Clinical Lectures on the Practice of Medicine. Lect. xxii. Dublin, 
1848. 

3 Op. cit. vol. i. p. 345. 4 Loc. cit. p. 107. 

5 Sanne : Op. cit. p. 179. 6 Loc. cit. 



THE THROAT AFFECTIONS OF THE ERUPTIVE FEVERS. 139 

warm poultices are the only local remedies that can be employed with 
advantage. The treatment of the plastic form of inflammation should 
be such as is recommended for primary diphtheria, viz., the internal use 
and local application of the persalts of iron, a highly nourishing diet, the 
free use of alcoholic stimulants well diluted, and the employment of anti- 
septic sprays and solutions. The practitioner must always bear in mind 
that tracheotomy may be necessary. 



Measles. 

The pharyngeal affection of measles is usually of slight importance, 
as in severe outbreaks of this fever the gravest lesions are manifested 
in the larynx, trachea, and bronchi. In many cases no eruption takes 
place on the mucous membrane of the throat, whilst in the great majority 
of instances, although more or less redness can be seen on inspection of 
the pharynx, the patient does not complain of any soreness of the throat. 
The enanthem appears at about the same period of the fever as the ex- 
anthem, i. e., in the course of the third or fourth day. False membranes 
may become developed after the subsidence of the general pyrexia, and 
occasionally even gangrene of some portions of the pharyngeal tissues 
may occur. 1 

The laryngeal disease may be either a simple catarrh, or true diph- 
theria. The catarrhal form of laryngitis may occur before the exanthem, 
or a day or two after the rash has come out, but in some epidemics it de- 
velops when the eruption has almost disappeared. 2 It is more common 
than the croupy form of disease, and though occasionally the inflamma- 
tion runs high, it is seldom of any importance. The principal symptom 
is obstinate hoarseness. In a number of Professor Hebra's patients in the 
General Hospital at Vienna, in different stages of measles, Dr. Stofella 3 
found a highly injected condition of the mucous membrane of the larynx 
in almost all the cases which he examined laryngoscopically. " This 
variety of croup," observes Dr. West, " seldom begins until the eruption 
of measles is on the decline, or the process of desquamation has com- 
menced. Its occurrence is most frequent from the third to the sixth day 
from the appearance of the eruption, but it oftener occurs at a later than 
at an earlier period." * Laryngeal diphtheria, or croup, is much more 
common than pharyngeal diphtheria. The prognosis is more unfavorable 
than in scarlatinal diphtheria, 80 per cent, of the cases terminating 
fatally. 

Treatment. — No special treatment is required for the catarrhal affec- 
tion, as spontaneous resolution takes place in seven or eight days. In 
the presence of false membrane, mortification or collapse, the same meas- 
ures must be adopted as recommended in the articles on diphtheria, croup, 
and putrid sore throat. 

Sma:.l-Pox. 

From the third to the sixth day of the eruption of variola the mucous 
membra?ie of the pharynx often becomes the seat of a crop of pustules 

1 See Barthez and Rilliet : Traite des Maladies des Enf ants, Paris, 1853. 

2 Bohn : Konigsberger Medizin. Jahrbucher, 1852. 

3 Wien. Medizin. Wochenschrift, Xos. 18, 19, 20, 18G2. 

4 Op. cit. p. 448. 



140 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

similar to those on the skin. In quantity they correspond, to some extent, 
to the abundance of the exanthem, and in severe cases they cause con- 
siderable inflammation and tumefaction in the throat, together with great 
pain in swallowing. Pustular sore throat, as Trousseau ' remarks, is also 
often accompanied by ptyalism, whereas in scarlatina this symptom is 
almost always absent. Ulcerations of sufficient depth to lay bare the mus- 
cular tissues occasionally occur in the malignant forms of confluent small- 
pox. 

77ie laryngeal affection may be a mild papular or pustular eruption of 
the mucous membrane, which causes little or no inconvenience, or it may 
be a diphtheritic process, which is often fatal. In the year 1863, through 
the courtesy of Mr. Marson, I was enabled to examine several patients in 
the Small-pox Hospital with the laryngoscope. In one patient laboring 
under severe purpuric small-pox, I found ecchymotic spots on the under 
surface of the epiglottis and on the mucous membrane over the arytenoid 
cartilages. In a convalescent case there was a distinct pustule on the 
edge of the epiglottis; in another instance, in which the entire body was 
covered with pustules, the larynx appeared perfectly healthy; and in an- 
other similar example there were no pustules, but there was marked con- 
gestion of the mucous membrane; in another instance the upper surface 
of the epiglottis was covered with pustules. Trousseau 2 mentions the 
circumstances of three cases that came under his own observation, where 
death took place from suffocation. " Three patients," he observes, " had 
arrived at the eleventh day of a variola, which up to that time had pur- 
sued a normal course. Suddenly they were seized by a frightful attack 
of suffocation, which carried them all off before sufficient time had elapsed 
for any one to come to their assistance. In one of these individuals 
traces were found at the autopsy of inflammatory lesions of the larynx 
and pustules of small-pox below the glottis." In another case 8 the post- 
mortem discovered oedema of the aryepiglottic folds, with an abscess as 
large as a pigeon's egg between the oesophagus and larynx. Riihle, who 
witnessed a bad epidemic of small-pox in Greifswald, in 1856-57, and 
who made no less than fifty-four post-mortem examinations, observes, 4 
" Although I have seen here and there pustule-like elevations, I never- 
theless consider the essential peculiarity of the laryngeal affection to be a 
croupous or diphtheritic inflammation." This author adds that as " out 
of the fifty-four cases there was not a single instance iu which the larynx 
and windpipe were in a normal state, he cannot but attribute a certain 
proportion of the mortality to the laryngeal affection." Pathological ex- 
amples of the diphtheritic complications of small-pox are to be found in 
the museums of St. Thomas's and St. Bartholomew's Hospitals and in 
other collections. In two instances I have known permanent paralysis of 
the adductor of a vocal cord follow small-pox; in both of these the larynx 
was affected at the time, and it is probable that the affection was of the 
diphtheritic character. 

Treatment. — In the milder class of cases, emollient gargles and w T eak 
astringent applications are useful. Suffocative attacks, dependent on 
oedema, must be met by scarification of the larynx, and in the worst cases 
by tracheotomy. In the diphtheritic form of disease treatment is almost 
useless, but the local remedies elsewhere recommended for primary diph- 
theria should be adopted. 



Loc. cit. p. 15 et seq. ■ Ibid. p. 16. 

Ibid. p. 20. 4 Op. cit. p. 247, 



THE THROAT AFFECTIONS OF TYPHOID FEVER. 141 



THE THROAT AFFECTIONS OF TYPHOID FEVER. 

Latin Eq. — Morbi gutturis inter febrem entericam. 
French Eq. — Maladies de la gorge de la fievre typhoide. 
German Eq. — Halsaffectionen beim Abdominaltyphus. 
Italian Eq. — Le malattie della gola nella febbre tifoide. 

Definition. — The throat affections of typhoid fever are of two kinds — 
(a) a low type of inflammation of the mucous membrane of the pharynx 
or larynx, leading in the latter situation to deep ulceration; and {b) 
secondary diphtheria. 

The pharynx is not invariably affected in enteric fever, the blood- 
poison more frequently provoking an attack of bronchitis or pneumonia. 
The mildest and most frequent form of pharyngeal lesion consists in a 
simple erythema of the mucous membrane of the mouth and fauces; and 
subjectively the affection occasions but little inconvenience beyond a dry- 
ness of the throat, and slight soreness in swallowing. The parts gradu- 
ally regain their natural condition as the convalescence of the patient 
becomes established. Occasionally an herpetic eruption is seen on the 
mucous membrane of the pharynx and mouth, which is attended by con- 
siderable pain in deglutition. This affection, which is only an accidental 
complication, though more severe than the erythematous condition, like 
it also undergoes spontaneous resolution, without leaving any ill effects. 

Secondary diphtheria is accompanied by the physical appearances 
and symptoms of the primary affection. 1 When this complication occurs 
in typhoid fever the prognosis is most unfavorable. Thus, out of six 
cases mentioned by Oulmont, 2 five terminated in death ; whilst Peter 3 
states that all the instances he has met with have proved fatal. 

In the larynx, as in the pharynx, both the inflammatory and the diph- 
therial affections are met with. The inflammatory changes have, as Dr. 
Wilks 4 has pointed out, a great disposition to end in ulceration. Ac- 
cording to Heinze, & out of 113 cases of typhoid fever examined at the 
Pathological Institution at Leipzig there were 13 cases of ulceration of 
the larynx. The ulceration sometimes involves a considerable surface, 
but it more frequently penetrates deeply and exposes the cartilages. It 
is generally at the posterior parts of the larynx, that is, at the under part 
in the prone position of a patient suffering from fever, that the disease is 
most frequently found ; and it is commonly thought to be caused, at least 
in part, by hypostatic influences. Frequently, however, the sides of the 
epiglottis and the inter-arytenoid folds are ulcerated, and the disease in 
this situation has been attributed to friction. The cricoid cartilage is 
often seen to be denuded, and of a blackish gray color ; and there is gen- 
erally a corresponding discoloration of the opposite wall of the pharynx. 
There is some liability to oedema, but the ulcerative process more often 



1 See a paper entitled Pharyngotyphus, in Giinburg's Zeitschrift, 1850, p. 155. 
■ Act. de la Soc. des Hop., 1859, 4e fasc. p. 30. 

3 Diet, des Sc. Med., Paris, 1864, vol. iv. p. 736. 

4 Trans. Path. Soc., vol. ix. p. 34. and vol. xi. p. 14. 
6 Die Kehlkopfsschwindsucht, Leipzig, 1879. 



142 

appears to originate in a typhous deposit — " laryngo-typhus being," as 
Rokitansky says, " the completion, as it were, of abdominal typhus." 
Tobold J states that the typhoid ulcer "commences in the mucous mem- 
brane as a circumscribed spot of congestion, which soon becomes yellow 
and depressed, sinks into the tissues, and losing its epithelium, constitutes 
the decubital-ulcer. From absorption of tissue the small ulcers gradually 
attain the size of a bean, and generally have irregular discolored edges." 
It is said that the cartilages often become independently diseased, i. e., 
become affected without the subjacent tissues being primarily involved. 
So many conditions of the larynx, however, are met with which tend to 
the destruction of the cartilages that it seems unnecessary to resort to 
the theory that these structures are independently diseased. The further 
pathological changes will be found described under " Perichondritis of 
the Larynx." Secondary diphtheria is not uncommon in typhoid fever, 
but from the unconscious condition of the patient it is very often over- 
looked during life, and only discovered at the post-mortem examination. 
Though it most frequently commences in the larynx, and is often con- 
fined to that part, the diminished supply of air causes little inconvenience, 
owing to the medulla having, to a great extent, lost its sensibility to im- 
pressions. The obstruction to respiration is also less marked, from the 
fact of the disease, in most cases, attacking adults. Diphtheria rarely 
occurs before the end of the second week. The prognosis is very unfa- 
vorable, the prostrate condition of the patient preventing the use of 
antiseptic inhalations or local applications. 

Treatment. — In the catarrhal affection soothing inhalations are useful. 
In the diphtheritic affection little can be done in the way of treatment, 
and there remains only the operation of tracheotomy, which in these 
cases offers little prospect of success. 



Typhus. 

The throat symptoms in typhus are similar to those met with in ty- 
phoid fever, but are much more rarely encountered. 



Intermittent Fever. 

Some practitioners make special mention of a sore throat connected 
with intermittent fever. 8 The affection is said to be characterized by 
periodicity, and to arise from palustral blood-poisoning. The treatment 
consists in the administration of quinine, as in cases of ague, the symp- 
toms of which are supposed to be only marked by the local phenomena 
in the throat. It is, however, by no means certain that an angina of this 
nature really exists, the evidence forthcoming on the subject being both 
scanty and inconclusive. 



1 Tobold: Laryn^oscopie, etc., Berlin, 1874, p. 207 et seq. 

2 Peter : Loc. cit .: also Desnos : Diet, de Med. et de Chir. Prat., vol. ii. p. 472. 



ERYSIPELAS OF THE PHARYNX AND LARYNX. 143 



ERYSIPELAS OF THE PHARYNX AND LARYNX. 

Latin Fq. — Erysipelas pharyngis et laryngis. 
French Fq. — Angine erysipelateuse. 
German Fq. — Erysipelas des Schlundes und Kehlkopfs. 
Italian Fq. — Risipola della faringe e della laringe. 

Definition. — Erysipelas of the mucous membrane of the pharynx and 
larynx pathologically similar to the same malady when situated on the 
skin, and occurring either primarily or by extension from the face along 
the mucous tracts of the mouth, nose, or ear. 

History. — The existence of an erysipelatous affection of the mucous 
tracts inside the body was recognized as early as Hippocrates, 1 who 
states : " When erysipelas extends from within outward it is a favorable 
symptom, but when it removes to the internal surfaces it is a deadly one. 
The signs of this occurrence are — disappearance of the external redness, 
with oppression on the chest, and difficulty of breathing." Subsequent 
writers studied the phenomena of the retrocession of erysipelas with more 
topical accuracy, and Fabricius Acquapendente ' 2 refers to a case of meta- 
stasis — a phenomenon of doubtful occurrence. During the eighteenth 
century many authors gave descriptions of erysipelas of the pharynx with 
more or less precision ; and in 1757, Darluc, 3 in recounting the facts of 
an epidemic of erysipelas which occurred at Caillan in 1750, expresses 
himself thus clearly: "In some cases the morbific matter extended to 
the throat, and caused difficulty of deglutition ; the voice became hoarse 
with a species of suffocation, swelling in the muscles of the neck, and all 
the symptoms of quinsy." Finally, in 18G2, Cornil 4 almost exhausted 
the subject in an excellent article containing cases which illustrate nearly 
every phase of the disease. 

Etiology. — The causes of erysipelas of the pharynx or larynx are evi- 
dently those of the same disease when situated on the external parts of 
the body. Thus most cases seem to recognize an epidemic or an endemic 
influence, whilst a small portion of the instances met with appear to oc- 
cur sporadically. The etiology with respect to age and sex has not hith- 
erto been established by a sufficient mass of statistics, but according to 
Cornil, 6 out of eighteen cases in which the pharynx was affected, fif- 
teen patients were under the age of thirty, and two-thirds of the cases 
were females. 

Symptoms. — When the disease is confined to the pharynx the primary 
phenomena vary considerably in different cases, and also diverge widely 
from the first symptoms of simple tonsillar inflammation. Previously to 
the efflorescence of erysipelas there is a well-marked febrile stage, in which 
the temperature sometimes rises as high as 104 ° Fahr. This initiatory 
fever may last for three or four days before any soreness is felt in the throat 
or the characteristic redness appears on the skin. In one class of cases — 

1 Coacae Prenotiones, lib. II. cap. xiv. 

2 Opera Chirurgica, Pars Prior, lib. I. cap. viii. 

3 Journal de Med. et de Pharmacie. juillet. 1757. 

4 Archiv. Generates de Med., 1862, t. xix. pp. 257, 443. 

5 Ibid. , p. 459. 



144 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

the majority — the pharyngeal disease occurs as an extension of a similar 
attack on the face, whilst in another the mucous membrane is first 
affected. Out of eighteen cases analyzed by Cornil, 1 the erysipelas twice 
appeared simultaneously on the face and in the pharynx, the throat was 
the primary seat of the disease seven times, and on nine occasions the 
skin was attacked first. The propagation of the malady from the face to 
the pharynx, and vice versa, was observed to take place by four different 
routes, viz.: (1) Most frequently by the lips and mucous membrane of the 
mouth ; (2) by the nasal fossa? ; (3) by the Eustachian tube, the middle 
ear, and the external auditory meatus, and (4) by the nasal fossag and the 
lachrymal sac and ducts to the conjunctiva and eyelids. In none of the 
cases was there any metastasis, but the disease spread by continuity of 
tissue, and the erysipelatous redness could be traced step by step along 
the paths indicated. In a case reported by Gull 2 the erysipelas spread- 
ing from the pharynx reached the face almost at the same time by the 
auditory and lachrymal channels. I have myself only met with four un- 
doubted cases of erysipelas of the pharynx. In three of these the disease 
spread from the pharynx to the face — twice by the nose, and once by the 
mouth and lips. In none of these cases was the diagnosis made out till the 
erysipelas reached the skin. In the other case the affection commenced 
in the auricle of the right ear and spread through the Eustachian tube to 
the uvula and left tonsil. The following were the sexes and ages of my 
patients : A man aged 58, and three women aged 47, 28, and 17. When 
the disease arrives at the pharynx, the patient complains of pain and 
difficulty in deglutition. Swelling of the submaxillary and cervical 
glands is almost constantly present, and to such an extent that, in many 
cases, the patient can scarcely open his mouth. Stiffness of the jaw from 
this cause is sometimes complained of before anything can be seen on the 
skin or in the pharynx, and there is often considerable ptyalism from im- 
plication of the parotid and salivary glands. The pharyngeal lesion may 
terminate in gangrene. s Jr> conjunction with so serious a phase of the 
disease, all the constitutional symptoms are much aggravated, and when 
mortification takes place the symptomatic fever assumes a low typhoid 
form, and there is a tendency to death by collapse. On inspecting the 
pharynx the appearance of the mucous membrane, when affected with 
erysipelas, differs considerably according to the form of the disease which 
is present ; the local phenomena are always very different from those of 
tonsillitis, but often cannot be distinguished from simple inflammation of 
the part. Cornil 4 makes three divisions of the malady, viz., (1) erysipe- 
las with simple redness ; (2) erysipelas with phlyctenular ; and (3) ery- 
sipelas terminating in gangrene. Thus it may be seen that erysipelas, 
when situated on the mucous membrane, tends to pursue a course exactly 
the same as when it affects the skin. In the first and mildest variety the 
pharynx presents a diffuse hue of deep purplish red, and has a shining- 
aspect as if the mucous membrane were covered with a varnish. A vari- 
able amount of cedematous swelling can also be generally perceived. 
The abnormal coloration extends over the veil of the palate and anterior 
surface of the uvula, over the pillars of the fauces and tonsils on both 
sides, and over the posterior wall of the pharynx. When bulla? arise, all 
the symptoms, both local and constitutional, are increased to an intensity 
which clearly indicates a severer expression of the disease. The vesicles 

1 Loc. cit. p. 449. 2 Medical Gazette, 1849, on the Alliances of Erysipelas. 

3 Cornil : Loc. cit. p. 453. 4 Ibid. p. 262. 



ERYSIPELAS OF THE PHARYNX AND LARYNX. 145 

vary in size from that of a millet seed to a small nut, last but a few hours, 
and are filled with serum, pus, or even with blood, according to the ob- 
servations of Cuire. 1 It is often very difficult, except by collateral signs, 
to distinguish these bullae from herpes. On their disappearance they 
leave in their place a whitish yellow patch of softened tissue, which is 
easily torn from the structures beneath by the act of swallowing or 
coughing. Under these circumstances, membranous shreds may be seen 
hanging at various points from the surface of the pharynx. Thus the 
greater part of the mucous membrane desquamates at the termination of 
such an attack. After this process has ceased, and all redness and pain 
have likewise disappeared, an injection of the superficial veins of the 
pharynx remains for a while, and constitutes for some time the last stage 
of the morbid action. Most cases terminate in resolution, but in a few 
instances the intensity of the inflammation has led to gangrene of por- 
tions of the mucous membrane and the submucous tissues. The occur- 
rence of mortification can be readily recognized by the characteristic 
odor, and by the dark, pultaceous appearance of the affected spots of the 
pharynx. In the four cases which I have seen, recovery took place, 
though in one instance abscesses formed on the ala of the nose and in 
the cheek. 

Erysipelas most commonly reaches the larynx by extension from the 
pharynx, but the former organ may be primarily affected, whilst the 
pharynx remains healthy. Porter 2 has described the case of a woman, 
aged 35, who was admitted into one of the Dublin hospitals, on account 
of enlarged spleen and anasarca of the extremities. Unfortunately, she- 
was placed in the next bed to a patient convalescent from erysipelas, and 
in a few days she took that complaint. The left eye first became swollen 
and the pharynx inflamed, and the disease soon extended to the larynx. 
The patient died comatose, from cedematous laryngitis, three days after 
the face was attacked. Sometimes the poison of erysipelas confines itself 
to the larynx, the skin being free from inflammation; at other times it 
passes from the larynx to the external parts. Cases of the former kind 
have been already placed on record by Cuire, 3 and another one is now 
added (see page 147). In erysipelas of the head and neck there is gene- 
rally more or less congestion of the mucous membrane of the larynx. 
Occasionally, though less frequently, the affection appears to originate in 
hospital-gangrene. 4 The symptoms of the disease are difficulty in swal- 
lowing, hoarseness or loss of voice, and pain, which is increased on pres- 
sure externally. Dr. Semeleder 5 examined four cases of erysipelas of the 
face, with the laryngoscope, and in all of them he found inflammatory 
redness and swelling of the epiglottis and larynx down to the vocal cords, 
though there was no dyspnoea or dysphonia. The inflammatory symptoms 
in the larynx disappeared gradually with the desquamation of the skin; 
and in one case a relapse of the cuticular affection was accompanied by a 
recurrence of laryngeal inflammation. Sometimes the disease is much 
more active and may result in an acute oedema, which rapidly tends 
toward a fatal termination. 

According to Peter 6 the malady may extend still further down the 



1 De l'Erysiptle du Pharynx, These de Paris, 1864, No. 136. 

1 Observations on the Surgical Pathology of the Larynx and Trachea, London, 1837, 
104 

3 Op. cit. pp. 73-77. 4 Ryland : Diseases of the Larynx, p. 8. 

5 Loc. cit. 6 Diet, des Sciences Med., Paris, 1860, vol. iv. p. 723. 

10 



146 

respiratory tract, and he states that in one instance he has seen it lead to 
" galloping consumption." 

Diagnosis. — The diagnosis of erysipelas of the pharynx and larynx 
cannot but remain doubtful except where it is accompanied by manifesta- 
tions on the skin. Indisputable as is the occurrence of erysipelas as an 
^nanthem, there are no pathognomonic signs by which the disease can be 
recognized when confined to the mucous tracts. 

Pathology. — Erysipelas consists essentially in a local manifestation on 
the skin or mucous tracts of a general blood-poisoning. When situated 
internally, the morbid action is confined to the mucous membrane and 
submucous tissues. The vessels of the part are loaded with effete ele- 
ments, and the cellular tissue becomes infiltrated with unhealthy serum. 
Where gangrene takes place the muscular fibres are softened and sepa- 
rated, but their substance is seldom destroyed. The course of the malady 
is too rapid for the process of sphacelus to extend deeply. In a case ex- 
amined by Cornil, 1 where the larynx had become affected, the aryepiglot- 
tic folds were reduced to a mass of " putrilage" but the cartilages were 
left intact. In another case reported by the same author, gangrene of 
the palate and death having supervened, the autopsy revealed softening 
of all the superficial structures of the pharynx. The mucous membrane 
was in several places reduced to a pulp, and the uvula was torn from the 
soft palate by a slight effort of traction. 

Progiiosis. — The local lesions occasioned by erysipelas are usually sub- 
ordinate to the severity of the general blood-poisoning. The intensity of 
the constitutional phenomena must guide us in giving a prognosis as to 
the probable termination of the attack. The dictum of Hippocrates, 
already referred to, has been confirmed by modern observation. Thus in 
nine cases analyzed by Cornil, 2 where the face was first attacked, seven 
deaths occurred, whereas in nine other instances where the enanthem pre- 
ceded the skin eruption, seven recoveries took place. The extension of 
erysipelas to the throat marks an increased intensity of the blood-poison- 
ing, and in the majority of cases the disease is not limited to the pharynx. 
It spreads down the windpipe and oesophagus, and by giving rise to oedema 
of the glottis, capillary bronchitis, and lesions of the alimentary canal, 
tends to a fatal issue. 

Treatment. — Both local and constitutional measures must be adopted 
in erysipelas of the throat. As regards topical applications, I -have seen 
benefit resulting in two cases of pharyngeal erysipelas from the insuffla- 
tion twice daily of morphia (gr. ^) diluted with starch, whilst ice was con- 
stantly sucked and bromide of potassium given every four hours. Hot 
soothing inhalations should not be used as long as there is any chance of 
arresting the inflammation. Should the disease terminate in gangrene, we 
must resort to antiseptic gargles of permanganate of potash, chlorate of pot- 
ash, carbolic acid, etc., whilst if oedema of the glottis become developed, re- 
course must be had to scarification of the larynx, and in extreme cases to 
tracheotomy. Perchloride of iron should be administered internally, and 
if the vital powers sink low, bark and ammonia, with a free allowance of 
stimulants, will be required. The diet throughout the whole course of the 
disease should be of the most nutritive description. 

The following case illustrates the rare form of the disease in which 
the larynx is affected with erysipelas, whilst the pharynx and skin are 
unaffected : 

1 Loc. cit. p. 446. 8 Loc. cit. p. 458. 



ERYSIPELAS OF THE PHARYNX AND LARYNX. 147 

ERYSIPELAS OF THE LARYNX LARYNGOTOMY DEATH. 

(Reported by Dr. Porter, now of St. Louis.) 

" James S , aged 35, a strong, vigorous man, was admitted into 

the London Hospital, January 19, 1874, for the fracture of the right in- 
ternal malleolus. For ten days the patient did very well, but then com- 
plained of pain in the throat and hoarseness. On the following day there 
was some dyspnoea, whilst the pain and hoarseness were more marked. 
His temperature was 102°, pulse 132, and respirations 36 to the minute. 
A laryngoscopic examination on the succeeding day discovered that the 
mucous membrane of the epiglottis and of the arytenoid cartilages was 
acutely inflamed. The ventricular bands were so much swollen as to cover 
the vocal cords. The patient was aphonic and the pain very intense. 
There was only very slight pharyngeal congestion. Inhalations of ben- 
zoin and mild astringent applications were used, and warm fomentations 
were applied to the neck. Dr. Morell Mackenzie saw the patient the 
next day, and found great tumefaction of the epiglottis, the mucous 
membrane of which was thickened and eroded. In consequence of the 
general swelling the vocal cords could scarcely be seen. The outer side 
of the neck was also somewhat tumefied. During that evening the patient 
became rapidly worse. Pulse 160 ; respirations 44 to the minute and 
labored ; temperature 103°. 

" Laryngotomy became necessary early in the night. There was con- 
siderable hemorrhage, but the patient appeared very much improved by 
the operation. On the next morning, a dark flush was seen around the 
tracheal wound; breathing was again difficult and dysphagia increased. 
There was a distinct friction sound at the apex of the heart, and dulness 
at the bases of both lungs. The following day the patient was much 
worse, and the flush around the wound had increased in size and density. 
The dyspnoea was more marked, and the dysphagia so great that no 
nourishment could be taken. Death ensued at ten o'clock that evening. 
[There were two cases of erysipelas in the same ward when the patient 
was admitted, and several of the attendants of the patients were sub- 
sequently attacked with sore throat.] 

" The autopsy showed that the heart was healthy, but the lungs were 
cedematous and of a dark color. The larynx was greatly altered, the 
mucous membrane covering the epiglottis and the arytenoid cartilages 
being swollen and ulcerated; the lining membrane of the bronchi was 
bright red. The traumatic affection of the leg showed no sign of ery- 
sipelas, the healing process appearing to have proceeded satisfactorily." 



SECTION II.-THE LARYNX. 



ANATOMY OF THE LARYNX. 

This complicated organ, which serves the double purpos'e of transmitting 
air and producing the voice, is situated between the hyoid bone above 
and the trachea below, having behind it the pharynx, and on each side 
of it the great vessels and nerves of the neck. When the head is held 
upright and the larynx is at rest, the middle of the thyroid cartilage is 
opposite the body of the fifth cervical vertebra, the whole organ from the 
tip of the epiglottis to the lower border of the cricoid cartilage corre- 
sponding to the third, fourth, fifth, and sixth cervical vertebrae. But the 
position of the larynx is very far from constant, as it ascends and descends 
to a variable degree during respiration, phonation, and deglutition. 

Viewed from the front, the general external configuration of the 
larynx is as follows : Passing from above downward there may be 
recognized by palpation, or indeed by mere inspection in thin persons: 
a protuberance (Pomum Adami) less prominent in females and boys 
before puberty, formed by the meeting in the middle line of the two alae 
of the thyroid cartilage; above the laminae is a deep notch, while below 
them is the depression for the crico-thyroid membrane, and again lower 
down the convexity of the cricoid cartilage. Laterally the quadrilateral 
laminae of the thyroid cartilage partially covered by the depressors of the 
hyoid bone may be made out, while below the lower border of the cricoid 
can be seen or felt a depression corresponding with the junction of that 
cartilage with the trachea. Still lower there may be noticed, in the 
middle line, a slight protuberance, the isthmus of the thyroid body, and 
on either side the lobes of this body, which vary considerably in their 
development, and in women, generally, give a more rounded form to the 
neck than in men. Below this crossing of the isthmus the trachea 
recedes between the converging sterno-cleido-mastoids, and finally dis- 
appears behind the suprasternal notch. 

The posterior surface of the larynx constitutes the anterior wall of 
the pharynx. 

The upper surface presents in front the ligament, which unites the up- 
per border of the thyroid cartilage with the hyoid bone, and the epiglottis 
with its five folds of mucous membrane; further back, the superior aper- 
ture of the larynx, cordiform in shape, descending in an inclined plane 
with the larger extremity in front, and limited anteriorly by the epiglot- 
tis, laterally by the ary-epiglottic folds, and behind by the apices of the 
arytenoid cartilages and the upper border of the arytenoid muscle covered 
with mucous membrane. 

The inferior surface of the larynx, corresponding with the lower edge 



ANATOMY OF THE LARYNX. 149 

of the cricoid cartilage, presents the ligament which unites that cartilage 
with the first ring of the trachea, and the annular opening into the wind- 

PiP e ' 

The consideration of the internal surface of the larynx is best de- 
ferred till the cartilaginous skeleton and other component parts have 
been described. 

The frameworK ci the larynx is composed of a series of cartilages, 
nine in number, three being single and three in pairs. The former are 
known as the thyroid and cricoid cartilages, and the epiglottis. The lat- 
ter are the arytenoids, and the cartilages of Wrisberg and Santorini. 
There are also the sesamoid cartilages. The chief portions of the laryn- 
geal framework are so articulated with one another by ligaments as to be 
capable of a considerable number of movements, which are produced by 
means of muscles, the function of which IS to place the vocal cords in the 
proper position for phonation. The internal surface of the cartilages, 
ligaments, joints, muscles, and vocal cords is covered by mucous mem- 
brane, and the entire apparatus is supplied with blood-vessels, lymphatics, 
and nerves. 

The thyroid cartilage Is thf largest portion of the laryngeal frame- 
work, and may be described as consisting of two symmetrical four-sided 
plates, united together in the middle line by an intermediate lamina. 
They include between them an angle of about 90°, and are somewhat ob- 
liquely inclined, so that their external surfaces look slightly downward. 
The inferior border of each plate is nearly horizontal, the posterior verti- 
cal, while the upper border is sinuous, being concave behind, and boldly 
convex in front. In the united plates this convexity leads to the forma- 
tion of a deep notch, which serves for the attachment of the thyro-hyoid 
membrane. The posterior angles of each plate present two hook-shaped 
processes, named respectively the greater and lesser cornua. The former 
projects upward and somewhat inward from the superior angle, and is 
connected by means of ligaments with the greater cornu of the hyoid 
bone. The latter projects downward and somewhat forward from the in- 
ferior angle, and presents on the inner surface of its extremity a facet for 
articulation with the cricoid cartilage. 

Placed immediately below the thyroid, and connected with it by means 
of the articulation just mentioned, is the cricoid cartilage. Its general 
form is that of a signet ring, the portion representing the seal being 
placed posteriorly, while the thin and narrow portion corresponding to 
the ring, but which in this case takes up only a fourth of the whole cir- 
cumference, is placed in front. Its inner surface is continuous with that 
of the trachea, being convex from above downward. Its external surface 
is plane, and presents in front a prominence between the attachments of 
the crico-thyroid muscles, posteriorly in the middle line a low vertical 
ridge, broader below than above, separating shallow depressions for the 
posterior crico-arytenoid muscles, and on each side an articular facet for 
the lesser cornu of the thyroid cartilage. This facet, which is circular in 
form and concave, looks upward, and is seated upon a wart-like promi- 
nence placed halfway between the upper and lower margins of the carti- 
lage, and slightly anterior to the facet for the arytenoid. The upper bor- 
der of the cartilage is horizontal posteriorly, but slopes rapidly downward 
and forward on each side, and ends in front in a broad but deep notch, 
to which is attached the crico-thyroid membrane. Just beyond its hori- 
zontal portion the upper border presents on each side a sloping oval facet 
for articulation with the corresponding arytenoid. The lower border is 



150 DISEASES OF THE PHARYNX, LARYNX. AND TRACHEA. 

horizontal, and is connected with the first ring of the trachea, slightly 
overlapping it anteriorly. 

The arytenoid cartilages are situated at the posterior part of the 
larynx and articulate with the cricoid, upon which they are very freely 
movable. They are pyramidal in shape with their apices flattened and 
curved toward the middle line, and their bases obliquely sloped off so as 
to have an inward aspect. They have attached to them both the vocal 
cords and ventricular bands. Each cartilage presents for examination a 
posterior, an anterior or lateral surface, an internal or median surface, 
and a base. The base, by means of which the cartilage articulates with 
the facet on the upper border of the cricoid, is concave from before back- 
ward, and presents two well-marked processes. One, the processus voca- 
lis, is a prolongation of the angle formed at the junction of the base with 
the lateral and median surfaces; it projects forward into the larynx, and 
gives attachment to the true vocal cord. The other, the processus mus- 
cularis, is connected with the external angle of the base, and gives attach- 
ment to the posterior and lateral crico-arytenoid muscles. 

The smaller cartilages may be briefly dismissed. The cartilages or 
cornicula of Santorini are two small masses of fibro-cartilage, about as- 
large as millet-seeds, and situated at the apex of the arytenoids. The 
cartilages of Wrisberg are two soft fibro-cartilaginous plates embedded 
in a group of mucous glands occupying the ary-epiglottic folds, and are 
occasionally wanting. The sesamoid cartilages are very far from constant,, 
but when present they occur in the form of two small elongated masses, 
attached by means of elastic fibres along the lateral border of each aryte- 
noid. 

The epiglottis is a fibro-cartilage, which varies somewhat in shape. 
When seen from behind it has a leaf-like form, with its stalk below and 
expansion above. Removed from the pharynx and placed with its ante- 
rior surface uppermost and stalk foremost, it has very much the shape of 
an elongated saddle. As seen with the laryngoscope it varies very much 
in appearance, according to its inclination in relation to the thyroid carti- 
lage, and according to the extent its expanded portion curls round on it- 
self. In adults it is, in most cases, almost vertical, but in children it is 
often obliquely horizontal — lower behind than in front. It is attached by 
its lower margin to the inner surface of the thyroid cartilage by means 
of a firm band of elastic tissue, and at this point forms a projection, which 
in life (seen from above) has a rounded form, and is called the cushion of 
the epiglottis. Its free upper margin rises above the base of the tongue, 
with which it is loosely connected by means of three reduplications of 
mucous membrane — the glosso-epiglottic folds. The anterior surface is 
concave vertically, and convex from side to side, while the posterior sur- 
face is curved in exactly reverse directions, and is pierced by numerous 
little pits, which contain the glandular opening on the surface of the mu- 
cous membrane. The margin of the epiglottis is sharp, and there is often 
a notch in the centre of its upper free edge. It gives attachment to the- 
ary-epiglottic and pharyngo-epiglottic folds of mucous membrane. 

The structure of the cartilages (with the exception of the epiglottis 
and cornicula) is hyaline; in the arrangement of the cells it differs from 
articular cartilage, but corresponds to the cartilages of the ribs, and like 
them is prone to ossify. The epiglottis and cornicula are fibre cartilages,, 
and in man do not become ossified. 

The ligaments of the larynx are: (1) the extrinsic, which unite the- 
larynx with other parts; (2) the intrinsic, which unite the different parts. 



ANATOMY OF THE. LARYNX. 151 

of the larynx together; and (3) the mixed, which serve both these uses. 
The extrinsic are the th yro-hyoid and the crico-tracheal. The thyro-hyoid 
ligaments are three in number, viz., the thyro-hyoid membrane in the 
middle line and the thyro-hyoid ligaments proper on either side. The 
thyro-hyoid membrane is a rather delicate band of elastic tissue, attached 
above to the posterior border of the body of the hyoid bone, and below to 
the margins of the superior thyroid notch. It has in front a bursa, and 
it is separated from the epiglottis behind by a considerable cushion of fat. 
The thyro-hyoid ligaments are cylindrical bands of fibro-elastic tissue 
uniting the greater cornua of the thyroid cartilage with the extremities 
of the hyoid bone. Between these ligaments and the thyro-hyoid mem- 
brane the hyoid bone is connected with the thyroid cartilage by means 
of a thin layer of fibrous tissue. The crico-tracheal ligament is a fine 
membranous expansion, w T hich extends from the lower border of the cri- 
coid cartilage to the first ring of the trachea. 

The intrinsic ligaments are the crico-thyroid, the crico-arytenoid, the 
superior thyro-arytenoid, and the inferior thyro-arytenoid (vocal cords), 
whose ligamentous use, however, is entirely subservient to their higher 
function. The crico-thyroid ligament is a band of elastic membrane 
attached in front to the upper border of the cricoid and the lower bor- 
der of the thyroid. The crico-arytenoid ligaments consist for the most 
part of scattered fibres, which assist in forming the capsule of the joint; 
on the posterior surface of the cricoid cartilage, however, near its upper 
border and outer corner, the ligamentous fibres are consolidated into a 
strong band, which is inserted into the posterior and inner surface of 
the arytenoid cartilage near its base. The superior thyro-arytenoid lig- 
aments consist of only a few scattered fibres, which are not continuous, 
and though, to a great extent, constituting the ventricular bands, scarcely 
deserve the name of ligaments; they are inserted anteriorly in the reced- 
ing angle of the thyroid cartilage, just above the insertion of the epiglot- 
tis. The inferior thyro-arytenoid ligaments are the most important struc- 
tures in the larynx — the most essential features of the organ. They are 
formed of strong bands of yellow elastic tissue, extending from the reced- 
ing angle of the thyroid cartilage, anteriorly, to the projecting angles at 
the base of the arytenoid cartilages (processus vocales). Examining them 
more in detail we find that each vocal cord is made up of fibres which are 
collected into a single band only at their anterior extremity; posteriorly 
they separate at an acute angle into three divisions; the first of these 
passes slightly upward, and is inserted just behind the posterior extrem- 
ity of the ventricle; the second is attached to the processus vocalis of 
the arytenoid cartilage and to the surface of the cartilage above the pro- 
cess, and the third, dividing into five or six small bundles, is attached to the 
lower part of the inner surface of the arytenoid cartilage, some of its 
fibres extending beneath the capsule of the crico-arytenoid articulation 
and reaching the upper border of the cricoid cartilage. The vocal cords 
are covered with the mucous membrane of the larynx, and the fibres of 
the thyro-arytenoid muscle assist in forming a large proportion of their 
substance. When a vocal cord is drawn toward the median line, and a 
vertical section is made through it parallel with the anterior surface of 
the spinal column, it is seen to be triangular or prismatic. Two sides of 
the triangle are free, one directed upward toward the ventricular band, 
the other downward and inward toward the lower part of the opposite 
side of the trachea, and the third is the outer and attached edge. Sound 
is produced by the vibrations of the vocal cords when approximated. 



152 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

The only mixed ligament is the epiglottic. It consists of an extrinsic 
and intrinsic portion. The former is composed of a central glosso-epi- 
glottic ligament uniting the anterior surface of the epiglottis to the root 
of the tongue, and two hyo-epiglottic ligaments passing outward from 
the middle of the anterior surface of the epiglottis to the extremities of 
the body of the hyoid bone. The intrinsic portion, or thvro-epiglottic 
ligament, is a firm but narrow fibrous band connecting the 'lower end of 
the epiglottis with the thyroid cartilage just below its notch. 

Between the cartilages and the mucous membrane of the larynx is a 
continuous layer of elastic fibrous tissue, which assists in supporting the 
general structure of the larynx, and effectually adds to its resiliency. It 
is attached below to the cricoid cartilage, becomes blended with the* crico- 
thyroid ligaments, and enters into the formation of the vocal cords; it lines 
the ventricles of the larynx, and, thickening again, forms the ventricular 
bands. It can be traced into the ary-epiglottic folds, and after becoming 
firmly attached to the thyroid cartilage, forms the ary-epiglottic liga- 
ments; anteriorly it becomes blended with the thyro-epiglottic and glosso- 
epiglottic ligaments. In those portions of the laryngeal tube where there 
are no ligaments connecting the movable cartilages with one another, 
this fibro-elastic lamina is very thin, and can be with difficulty separated 
from the mucous membrane. 

The articulations of the larynx consist of the crico-thyroid and crico- 
arytenoid articulations, and the fibrous connections between the arytenoids 
and the cartilages of Santorini. The crico-thyroid articulation is com- 
posed of two true joints placed laterally, by means of which the lesser 
cornua of the thyroid cartilage articulate with the circular facets on the 
cricoid. These joints are provided with articular cartilages, synovial 
membranes, and capsular ligaments, and the movements they admit of 
are those of flexion and extension. The crico-arytenoid articulations con- 
sist of the two joints between the bases of the arytenoids and the facets 
on the upper border of the cricoid. Each joint is saddle-shaped, and is 
provided with a synovial membrane and a lax fibrous capsule, admitting 
of a very extensive series of movements. The articulation between each 
arytenoid and the corresponding cartilage of Santorini consists of a thin 
layer of fibro-elastic cartilage, which admits of very free movement in 
every direction. 

The muscles of the larynx may be divided, for purposes of description, 
into three sets: First, a well-defined group on the anterior surface, con- 
necting the cricoid cartilage with the lower border of the thyroid, and 
termed the crico-thyroidei; secondly, a pair of triangular muscles on the 
posterior surface of the cricoid cartilage, known as the crico-arytenoidei 
postici or abductors of the vocal cords; and, lastly, a group of smaller 
muscles in the upper part of the larynx, arranged in a somewhat sphinc- 
ter-like manner, and including the thyro-ary-epiglottici, the arytenoideus, 
the thyro-arytenoidei externi and interni, and the crico-arytenoidei later- 
ales or adductors. All the laryngeal muscles, with the exception of the 
arytenoideus, occur in pairs. 

The crico-thyroideus muscle of each side may be easily shown, on dis- 
section, to consist of two layers of fairly well-defined muscle, triangular in 
shape. In the superficial layer, the fibres pass in a more or less vertical 
direction, and this portion has been termed on this account the crico- 
thyroideus rectus. In the deeper layer, the oblique arrangement of the 
fibres has caused the muscle to be known as the crico-th'yroideus obliquus. 
The former is attached below to the anterior surface of the cricoid carti- 



ANATOMY OF THE LAEYK*. 



jage close to the middle line, and spreading out as it ascends Is inserted 
into the anterior third of the lower margin of the corresponding 1 thyroid 
plate. The crico-thyroideus obliquus springs from the narrow anterior* 
surface of the cricoid by two heads which embrace the attachment of the 
crico-thyroideus rectus, and running obliquely upward and backward is 
inserted into the posterior two-thirds of the lower margin of the cor- 
responding thyroid plate, and the whole anterior border of the lesser 
horn. 

The crico-arytenoideus posticus is a flat triangular muscle, which arises 
from a shallow depression external to the median ridge on the posterior 
surface of the cricoid ; its fibres converge as they pass upward and out- 
ward, and are inserted into the posterior margin of the base of the corre- 
sponding arytenoid cartilage, between the attachments of the arytenoideus 
and crico-arytenoideus lateralis. 

The third group of laryngeal muscles, the arrangement of which, as 
already remarked, bears some resemblance to a sphincter, may be divided 
into three layers. The outermost layer consists of the two thyro-ary- 
epiglottici ; the middle layer of the arytenoideus, the thyro-arytenoidei ex* 
terni, and the crico-arytenoidei laterales ; while the innermost layer con- 
sists of the two thyro-arytenoidei interni. 

The thyro-ary-epiglotticus is a flat, narrow muscle, which, taking ori- 
gin from the processus muscularis of the arytenoid cartilage, passes up- 
ward and inward, crosses its fellow in the middle line, and is inserted 
into the upper half of the lateral border of the arytenoid of the opposite 
side, and the posterior border of the corresponding cartilage of Santo- 
rini. The lower fibres, after their attachment to the arytenoid, run for- 
ward and slightly downward, to be inserted into the thyroid cartilage neai 
its receding angle, while the fibres which are attached to the Santorinian 
cartilage are continued forward and upward into the ary-epiglottic fold, 
where they are joined by certain scattered fibres which arise from the 
thyroid cartilage, close to the anterior attachment of the muscle. 

The arytenoideus is a flat quadrilateral muscle attached to the lateral 
borders of the arytenoid cartilages, and running horizontally between 
these attachments. It is covered posteriorly by the thyro-ary-epiglottici, 
while in front it is in direct relation with the laryngeal mucous membrane. 
The thyro-arytenoideus externus usually consists of three portions, a lower, 
middle, and upper, the two latter being, however, occasionally absent. 
The lower portion may again be divided into two layers, an external and 
an internal. These arise side by side from the lower half of the internal 
surface of the thyroid cartilage, close to its receding angle, and from the 
iibrous expansion of the crico-thyroid ligament, and pass backward to 
oe inserted into the lateral border of the arytenoid cartilage. The inner 
portion runs in a horizontal direction, and is attached to the lower half 
of this border, while the outer portion passes obliquely upward, to be at- 
tached to the upper half, some of its fibres passing to the cartilage of 
\\ risberg and the ary-epiglottic fold. The middle portion of the thyro- 
arytenoideus externus takes origin from the angle of the thyroid cartilage 
close to its upper notch, and running obliquely downward is inserted into 
the processus muscularis of the arytenoid cartilage. The upper portion 
of the muscle is also attached to' this process, but its upper attachment is 
to the lateral border of the epiglottis, and it serves the same function, 
and sometimes takes the place of the ascending fibres of the thyro-ary- 
epigiotticus. The crico-arytenoideus lateralis arises from about the middle 
third of the upper border of the cricoid cartilage, and is inserted into the 



154 DISEASES OF TPIE PHARYNX, LARYNX, AND TRACHEA. 

whole anterior margin of the base of the arytenoid, a few fibres occasion- 
ally passing on to join the thyro-ary-epiglotticus. 

The thyro-arytenoideus internus is a prism-shaped muscle, which arises 
from the angle of the thyroid cartilage, just internal to the origin of the 
thyro-arytenoideus externus, and running parallel to, and in the substance 
of the vocal cord, is inserted into the apex and upper and lower surfaces 
of the processus vocalis. On transverse section it is seen to have three 
borders, the inner of which projects into the vocal cord, while the two 
outer and the side of the muscle between them lie upon the inner surface 
of the thyro-arytenoideus externus of the same side. 

Lastly, there remains to be mentioned a muscle which is only excep- 
tionally present, and which has been variously termed the crico-thyroideus 
posticus, and the kerato-cricoideus. It consists of a narrow band of 
fibres which arises from the posterior surface of the cricoid cartilage just 
below the origin of the crico-arytenoideus posticus, and passing upward 
and outward is inserted into the posterior margin of the lesser cornu of 
the thyroid cartilage. 

The laryngeal muscles have two different functions to perform. They 
have, first, to control the entrance into the larynx, opening it and closing 
it as circumstances may require ; and, secondly, to provide for the proper 
tension of the vocal cords during phonation. These functions, however, 
are not entirely independent of each other. The muscles which narrow or 
close the entrance to the larynx include, in the first place, all those fibres 
which ascend to be attached to the epiglottis, as well as those which 
encircle the vestibule; secondly, the laryngeal inlet is constricted by the 
arytenoideus, which approximates the arytenoid cartilages to each other ; 
thirdly, the true glottis is closed by the action of the thyro-arytenoidei 
interni and the crico-arytenoidei laterales, both of which muscles are able 
to rotate the arytenoid cartilages on their bases, and to approximate their 
vocal processes. The contrary action, viz., the widening of the glottis, 
is effected by the crico-arytenoidei postici, which rotate the arytenoid carti- 
lages outward, and so separate the posterior attachments of the vocal cords. 
The muscles whi-ch preside over the tension of the vocal cords are the 
crico-arytenoidei postici, the crico-thyroidei obliqui and recti, and the 
thyro-arytenoidei interni. The first-named muscles fix the arytenoid carti- 
lages upon the cricoid ; the crico-thyroidei draw the angle of the thyroid 
cartilage forward and downward in relation to the cricoid ; while the 
thyro-arytenoidei interni, by their contraction and expansion, produce 
in the vocal cords the degrees of tension necessary for the production of 
notes of different pitch. 

The arteries of the larynx are the superior laryngeal, the middle laryn- 
geal or crico-thyroid, and the inferior or posterior laryngeal. The supe- 
rior laryngeal is in most cases derived from the superior thyroid, though 
it occasionally springs immediately from the external carotid. Running 
almost directly inward between the greater horn of the hyoid bone and the 
upper border of the thyroid cartilage, it passes beneath the thyro-hyoid 
muscle and enters the larynx by perforating the thyro-hyoid membrane. 
Having sent an epiglottic branch upward, it passes obliquely downward 
toward the middle of the lower border of the thyroid plate, supplying in 
its course the muscles and the mucous membrane in the upper part of the 
larynx. Just before reaching the lower border of the thyroid cartilage it 
divides into two terminal branches, the larger of which anastomoses with 
the crico-thyroid, and the smaller with the inferior laryngeal artery. The 
middle laryngeal or crico-thyroid artery arises from the superior thyroid 



ANATOMY OF THE LARYNX. 155 

nearly opposite the upper margin of the thyroid cartilage, and passes down- 
ward and forward, lying upon the thyro-pharyngeus and thyro-hyoid 
muscles. Arrived at the lower border of the thyroid cartilage it divides 
into two branches, the outer of which passes into the larynx below the 
inferior margin of that cartilage, and joins a branch of the superior laryn- 
geal, while the inner division, uniting with its fellow on the opposite 
side, perforates the crico-thyroid ligament and is distributed to the laryn- 
geal mucous membrane below the vocal cords. The inferior or posterior 
laryngeal artery is derived from a branch of the inferior thyroid, and 
passing upward, together with the inferior laryngeal nerve, behind the 
crico-thyroid articulation, divides into two branches, one of which unites 
with a branch of the superior laryngeal, while the other is distributed to 
the crico-arytenoideus posticus muscle. 

The veins of the larynx for the most part have a similar arrangement 
to that of the arteries, but their anastomoses with each other and with 
the veins of the thyroid glands, the root of the tongue and the trachea, 
are more numerous. They terminate in the internal jugular. 

The lymphatics of the larynx are abundantly supplied to the mucous 
membrane, but the cartilages, muscles, and ligaments are described as 
being entirely destitute of them. They are arranged in the form of a 
thick network, which closely follows the arrangement of the mucous 
membrane, but the vessels are much narrower and the meshes much wider 
on the posterior surface of the epiglottis and along the true cords than 
in other parts of the laryngeal surface. The lymphatic capillaries of the 
larynx unite together to form lymphatic trunks at four different points, 
two of which are situated above the right and left ventricle respectively, 
and two below the cricoid cartilage, one on each side. The upper trunks 
receive the lymphatics from the epiglottis and from the upper and middle 
compartments of the larynx, and pass outward between the greater cor- 
nua of the hyoid bone and the upper border of the thyroid cartilage to 
join lymphatic glands. The lower trunks receive the lymphatics from the 
lower compartment of the larynx, and terminate in lymphatic glands, 
situated on either side of the trachea. 

The nervous supply of the larynx is derived from the superior and 
inferior or recurrent laryngeal nerves. These are branches of the pneu- 
mogastric nerve, but there is considerable evidence to show that those 
fibres which are derived from the spinal accessory nerve go, at least in 
part, to the laryngeal branches. The former is for the most part a sen- 
sory nerve, but it supplies a motor branch to one group of muscles, the 
crico-thyroids. The remaining laryngeal muscles are supplied from the 
inferior laryngeal, which is exclusively a motor nerve. 

The superior laryngeal nerve divides into two branches opposite the 
greater cornu of the hyoid bone. The external or smaller branch descends 
over the thyro-pharyngeus muscle to the lower border of the thyroid plate, 
where it enters the crico-thyroid muscle. The internal branch enters the 
larynx by perforating the thyro-hyoid membrane, and passing inward 
and slightly backward, directly beneath the mucous membrane forming 
the floor of the sinus pyriformis, divides into numerous branches, which 
pass upward, inward, and downward. Some of these branches, the pha- 
ryngeal, are distributed to the mucous membrane of the pharynx as low 
down as the lower border of the cricoid cartilage, as well as to the sinus 
pyriformis and outer layer of the ary-epiglottic fold. Other branches, the 
laryngeal, supply the whole internal surface of the larynx. 

The right recurrent nerve is given off from the pneumogastric just 



156 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

below the level of the commencement of the ascending portion of the 
right subclavian artery, and, passing behind the carotid artery, ascends 
between the trachea and oesophagus, where it pierces the inferior con» 
strictor and enters the larynx close behind the crico-thyroid articulation. 
In the first part of its course it is in proximity to the apex of the right 
lung. The left recurrent nerve is given off by the left pneumogastric on 
a level with the lower border of the arch of the aorta, and, winding round 
the transverse portion of the arch, it ascends to the larynx. After en- 
tering the larynx the nerves divide into branches which supply the laryn- 
geal muscles. 

The inner surface of the larynx may be divided into three portions* 
an upper, middle, and inferior, lying immediately one above another, and 
easily denned by natural limits. 

The uppermost of these spaces, or vestibule of the larynx, is of a some- 
what tubular form, but, owing to its sloping upper aperture, of greater 
depth in front than behind. It is bounded by the different cartilages, 
united together by reduplications of mucous membrane. Its upper 
boundary is identical with that of the larynx above described, while its 
lower margin is formed by the ventricular bands. The anterior wall of 
the vestibule is formed by the epiglottis, and is convex in its upper third 3 
concave in its middle third, corresponding to the insertion of the 
pharyngo-epiglottic folds, while its lower third is a boldly projecting^ 
round protuberance, the epiglottic cushion, the inferior border of which, 
becoming gradually smaller, changes into a sort of triangular gutter 
between the anterior extremities of the ventricular bands. The lateral 
walls of the vestibule, which form a furrow with the anterior, decrease 
in depth from before backward, and are formed by the ary-epiglottic 
ligaments, and their reduplications of mucous membrane. The posterior 
wall is formed by the cartilages of Santorini, and those segments of the 
arytenoid cartilages to which are attached the superior vocal cords. 

The middle compartment of the larynx is bounded above by an 
imaginary plane uniting the ventricular bands below by the true cords, 
while its lateral boundaries are the two ventricles or pouches of Morgagni 
contained between these structures. The aperture between the ventricu* 
lar bands is mote or less oval in shape, but wider behind than in front; ifc 
slopes obliquely downward and backward, and terminates in the fissure 
separating .he arytenoids. The inferior boundary of the cavity is con- 
stituted by the true vocal cords, the space between them being known 
as the rima glottidis. This space is in the adult about four-fifths of an 
inch in engtfa, and, when the vocal cords are separated to their utmost, 
about na±f an inch across at its widest part. The glottis is larger in life 
than the cadaveric position of the vocal cords would indicate, the ab- 
ductors being more powerful than the adductors. During quick inspira- 
tion and expiration, a condition corresponding with its greatest distention, 
its form is that of an isosceles triangle with its base posterior and its 
angles rounded off, but en forcible expiration, the edges of the rima 
approximate, and the vocal cords become parallel. The ventricle of Mor- 
gagni is oblong in shape, extending for about the length of the cords, 
and having externally the thyro-arytenoid muscle, and its mucous cover- 
ing. Its external wall presents two crescentic folds of mucous membrane^ 
between which is a deep fossa, and posteriorly a smaller funnel-shaped 
depression; while passing upward to the vestibule, between the carti- 
lages of Santorini and Wrisberg, is a shallow channel, the filtrum. 

The inferior laryngeal space is bounded by the cricoid cartilage, ine 



ANATOMY OF THE LARYNX. 15 f 

lower half of the angle of the thyroid cartilage, the vocal processes of the 
arytenoid cartilages, and the elastic and mucous structures, which extend 
downward from the free borders of the vocal cords; laterally the walls of 
this space diverge below the cords to the calibre of the commencement of 
the trachea. 

The internal surface of the larynx is covered throughout by a mucous 
membrane, continuous above with that of the tongue and pharynx and 
below with that of the trachea. In passing from the root of the tongue 
in front to the anterior surface of the epiglottis, it presents three well- 
marked reduplications — the glosso-epiglottic folds — one central and two 
lateral, including between them two shallow fossa?. Laterally it descends 
from the pharynx over the palato-pharyngeus muscle, to be attached to 
the upper portion of the inner surface of the thyroid cartilage, whence it 
passes again upward, external to the thyro-ary-epiglotticus, to form the 
outer layer of the ary-epiglottic fold. The fossa thus formed is termed 
the sinus pyriformis. In front of the vestibule the mucous membrane is 
firmly attached to the posterior surface of the epiglottis, and below that 
cartilage to the receding angle of the thyroid, forming a well-marked fur- 
row between the anterior attachments of the ventricular bands. The 
mucous membrane covering the lateral wall of the vestibule is smooth in 
front, but as it approaches the middle line behind, it dips slightly down 
between the Wrisbergian and arytenoid cartilages to form the filtrum, a 
shallow furrow, which passes downward and forward, and ends in the 
ventricle of Morgagni. Still further back the mucous membrane is firmly 
attached to the median surface of the arytenoid cartilage. Passing down- 
ward, the mucous lining of the vestibule is continued over the ventricular 
band, to which it is somewhat loosely attached, into the ventricle of the 
larynx. It covers the whole internal surface of this cavity, presenting 
the folds and fossa? which have been described above, and passing again 
inward attaches itself firmly to the sharp edge of the true cord. Between 
the cords, posteriorly, it loosely covers the anterior surface of the aryte- 
noideus muscle, being thrown into vertical folds on the contraction of 
this muscle, and the resulting approximation of the arytenoids. Below 
the vocal cords the mucous membrane is attached rather closely to the 
inner surface of the cricoid cartilage, whence it is continued downward 
to form the tracheal lining. 

The laryngeal mucous membrane presents both tesselated and ciliated 
epithelium. The latter has the more general distribution, the tesselated 
cells being confined to the upper and under surfaces of the epiglottis, to 
a narrow zone just within the upper aperture of the larynx, and to the 
projecting edges of the true cords, which are covered by a band of large, 
flattened, angular cells. In these parts the epithelial layer is in direct 
contact with the mucosa, but, elsewhere, it rests upon a transparent 
homogeneous basement or limitary membrane, a structure which plays an 
important part in the pathology of laryngeal diphtheria. It occasionally 
presents itself as an entirely independent layer, which can be separated 
without difficulty from the subjacent structures, but as a rule it is inti- 
mately connected with the fibrous tissue of the mucosa. According to 
Luschka, however, a homogeneous basement membrane only exists in the 
vicinity of the true cords, and even here it contains both fibrilke and 
colonies of cellular elements. The mucosa itself consists of a connective 
tissue of delicate fibrils enclosing numerous proliferating masses of cells. 
These cells, which are finely granular, and consist of a distinct nucleus 
enclosed in a thin layer of protoplasm, vary considerably in size and num- 



158 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

ber, being least numerous in the mucous covering of the true cords. 
Luschka regards them as the real matrix of the laryngeal epithelium, and 
assigns them an important share in all inflammatory affections of the 
larynx. The presence of these proliferating cell-masses is the chief dis- 
tinguishing mark between the mucosa and the next layer of the mucous 
membrane, the submucosa. The latter consists of numerous wavy elastic 
fibrillar, which run more or less parallel to the surface and are, as a rule, 
longer and somewhat coarser than the fibres of the mucosa. They en- 
close here and there spindle-shaped cells, which consist of an elongated, 
iinely granular nucleus, and a thin layer of protoplasm, prolonged at one 
end into a wavy, tail-like process. The laryngeal mucous membrane 
presents very few papillae, and these only in certain limited regions, viz., 
upon the anterior surface of the epiglottis, and along the edge of the 
true cords. Throughout the larynx the mucous membrane is richly pro- 
vided with glands, which occur both solitary and in groups. They are 
plentifully scattered over the prominence of the base of the epiglottis, 
along the furrows on each side of that cartilage, in the neighborhood of 
the cartilages of Wrisberg, on the ventricular bands, and throughout the 
walls of the ventricles, with the exception of the upper surfaces of the 
vocal cords. They are also irregularly distributed over the posterior wall 
of the larynx, especially in the neighborhood of the crico-arytenoid ar- 
ticulations. 

For further details the anatomical student is referred to the following 
works which have been largely laid under obligation by the author: — 
Luschka: " Der Kehlkopf des Menschen," Tubingen, 1871; Henle: 
" Handbuch der systematischen Anatomie des Menschen," Zweite Auflage, 
Braunschweig, 1873; and "Manual of Human and Comparative Histol- 
ogy," by Professor Strieker, translated by Henry Power, M.B. New 
Sydenham Society's Trans., London, 1872. 



THE LARYNGOSCOPE AND ITS ACCESSORY APPARATUS. 

History of its Invention. — There is no trace of a laryngoscope before 
the middle of the eighteenth century, but in the year 1713 M. Levret, a 
distinguished French accoucheur, whose highly inventive genius had led 
him to contrive surgical instruments of almost every description, occupied 
himself in discovering means, whereby polypoid growths in the nostrils, 
throat, ears, and other parts, could be tied by ligatures. 1 It is unneces- 
sary to describe here the various ingenious instruments which he invented 
for the purpose, but it may be observed that in using them he employed 
a speculum which differed from the various specula oris then in use. It 
consisted mainly of a plate of polished metal (plaque polie), which "re- 
flected the luminous rays in the direction of the tumor," and at the same 
time received the image of the tumor on its reflecting surface. 

About the year 1804, a certain Dr. Bozzini, of Frankfort-on-the-Main, 
caused a great sensation throughout Germany, with his invention for il- 
luminating the various canals of the body. He had made known his ideas 
a few years previously, but it was not till 1807 a that he published a work 

1 Mercure de France, 1743, p. 2434. 

8 Der Lichtleiter, oder Beschreibung einer einfachen Vorrichtung, und ihrer An- 
wendung zur Erleuchtung innerer Hohlen und Zwischenriiume des lebenden animal- 
ischen Korpers. Von Philipp Bozzini, der Medizin und Chirurgie Doctor, Weimar, 1807. 



THE LARYNGOSCOPE AND ITS ACCESSORY APPARATUS. 159 



•on the subject. Bozzini's invention consisted of two essential parts: 
First, a kind of lantern; and, secondly, a number of hollow metal tubes 
(specula) for introducing into the various canals of the body. The lan- 
tern was a vase-shaped apparatus made of tin, in the centre of which was 
.a small wax candle. In the side of the lantern there were two round 
holes, a larger and a smaller one, opposite each other. To the smaller one 
an eye-piece was fixed, to the larger the speculum was fitted. The flame 
of the candle was situated just below the level of these two apertures. 
The mouth of the speculum — 
a tube of polished tin or sil- 
ver — was always of the same 
size; but the diameter of the 
tube beyond its orifice varied 
according to the canal into 
w r hich it had to be intro- 
duced. The apparatus was 
about thirteen inches high, 
two inches from before back- 




ward, and rather more than 



Fig. 11. — Bozzini's Laryngeal Speculum {after Hufeland). 
In the drawing from which this is taken, the mirrors are direct- 
ed upward, as they would be when employed in rhinoscopy. 

three from side to side. In 

employing reflected light, Bozzini had the speculum divided by a vertical 
partition, so that there were, in fact, two canals and two mirrors. One 
of these mirrors was intended to convey the light, the other to receive 
the image. 

In the year 1825, 1 M. Cagniard de Latour, the successor of Savart at 
the French Academy of Sciences, and like him, an earnest investigator 
of the physiology of the voice, made an unsuccessful endeavor to examine 
the larynx during life. 

In the year 1827, 2 Dr. Senn, of Geneva, " had a little mirror con- 
structed for introduction to the back of the pharynx; with it he tried to 
see the upper part of the larynx — the glottis; but he gave up its use on 
account of the small size of the instrument." 

In the year 1829, 3 Dr. Benjamin Guy Babington exhibited at the 
Hunterian Society of London an instrument closely resembling the laryn- 
goscope now in use. Two mirrors were employed, one smaller, for receiv- 
ing the laryngeal image, the other larger, for concentrating the solar rays 
on the first. The patient sat with his back to the sun, and, whilst the 
illuminating mirror * (a common hand looking-glass) was held with the 
left hand, the laryngeal mirror — a glass one coated with quicksilver — was 
introduced with the right. 

In the year 1832, 5 Dr. Bennati, of Paris, used an instrument made by 
one of his patients named Selligue. It consisted of a double-tubed specu- 
lum, one tube of which served to carry the light to the glottis, and the 
other to bring back to the eye the image of the glottis reflected in the 
mirror, placed at the guttural extremity of the instrument. 

In the year 1838, 6 M. Baumes exhibited at the Medical Society of 



1 Physiologie de la Voix, par Edouard Fournie, Paris, 1865, p. 352. 

2 Journal des progres des sciences, etc., 1829, p. 231, note. 
:! Lond. Med. Gaz. , London. 1829, vol. iii. p. 555. 

4 Illustrations of this instrument will be found in my work on The Laryngoscope, 
3d edition, p. 14. 

5 Recherches sur le Mecanisme de la Voix Humaine, p. 37, note. 

6 Compte rendu des Travaux de la Societo de Medecine de Lyons, 1836-38, p. 62. 



160 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

Lyons a mirror about the size of a two-franc piece, which he described as 
being very useful for examining the posterior nares and larynx. 

In the year 1S40, 1 Liston, in treating of oedematous tumors which ob- 
struct the larynx, observed as follows: "The existence of this swelling 
may often be ascertained by a careful examination with the fingers, and 
a view of the parts may sometimes be obtained by means of a speculum — 
such a glass as is usecl by dentists on a long stalk, previously dipped in 
hot water, introduced with its reflecting surface downward, and carried 
well into the fauces." 

In the year 1844, 2 Dr. Warden, of Edinburgh, conceived the idea of 
employing a prism of flint glass for obtaining a view of the larynx. 

In the year 1S-44, 3 Mr. Avery, of London, invented a laryngoscope in 
principle very similar to that now in use. The reflector was attached to 
a frontal pad, and was retained in its place by two springs which passed 
over the operator's head to the occipital protuberance, where there was a 
counter-pad. There were two defects, however, in Avery's apparatus: 
the one was, that the laryngeal mirror (instead of being fixed to a slender 
shank) was placed at the end of a speculum; the other, that instead of 
employing the reflector for receiving the rays from a lamp placed on the 
table or elsewhere, Avery used his large circular mirror for the purpose 
of increasing the luminous power of a candle held near the patient's 
mouth. 

In the laryngoscope of Bozzini and Avery the lamp and the reflector 
are combined, whilst in the modern instrument they are separate. The 
laryngeal mirror of Bozzini and Avery was placed at the end of a specu- 
lum: Czermak's was a modification of the dentist's mirror. Mr. Avery's 
invention was not placed on record till some time after the modern laryn- 
goscope had come into use. 

In the year 1854,* "the idea of employing mirrors for studying the- 
interior of the larynx during singing " occurred to Signor Manuel Garcia. 
He had often thought of it before, but, believing it impracticable, had 
never attempted to realize the idea. The efforts of Signor Garcia, who 
was quite unaware that any similar attempts had previously been made in 
the same direction, were crowned with success, and the following year he 
presented a paper to the Royal Society of London, entitled " Physiologi- 
cal Observations on the Human Voice." 5 This paper contained an ad- 
mirable account of the action of the vocal cords during inspiration and 
vocalization ; some very important remarks on the production of sound in 
the larynx; and some valuable reflections on the formation of chest and 
falsetto notes. Signor Garcia's laryngoscopic investigations were all 
made on himself; indeed, he was the first person who conceived the idea 
of an autoscopic examination. His method consisted in introducing a little 
mirror, fixed to a long stem, suitably bent, to the top of the pharynx. He 

1 Practical Surgery, 1840, 3d edition, p. 417. 

2 Royal Scottish Society of Arts. Description, with illustrations, of a Totally Re- 
flecting Prism for Illuminating the Open Cavities of the Body, etc., etc.. May, 1844 ; 
see also Lond. Med. Gaz. , vol. xxiv. p. 256. 

3 Med. Circ, June. 1862, vol. xx. ; and Introduction to the Art of Laryngoscopy, 
by Dr. Yearsley, London, 1862. The instrument is figured on page 24 of my work on 
The Laryngoscope. 

4 Notice sur T Invention du Laryngoscope, par Paulin Richard, Paris, 1861 ; see M. 
Garcia's letter to Dr. Larrey, dated May 4, 1860 (p. 12 in Richard's pamphlet). 

5 Proc. Royal Society of London, vol. vii. No. 13, 1855 ; Philosoph. Magazine and 
Journal of Science, vol x. p. 21$; and Gaz. Hebdom. de Med. etChir., Nov. 16, 1855, 
No. 46. 



T?HE LARYNGOSCOPE AND ITS ACCESSORY APPARATUS. 161 

directed that the person experimented upon should turn toward the sun, 
so that the luminous rays falling on the little mirror should be reflected 
into the larynx; l but he added in a foot-note, that "if the observer ex- 
periments on himself, he ought, by means of a second mirror, to receive 
the rays of the sun, and direct them on the mirror which is placed against 
the uvula." Signor Garcia's communication to the Royal Society, though 
causing little stir at the time, was destined to create a new era in the 
physiology and pathology of the larynx. Treated with apathy, if not 
with incredulity, in England, his paper passed into the hands of Dr. 
Tiirck, of Vienna, and soon effected a revolution in the investigation and 
treatment of laryngeal disease. 

In the year 1857, 2 during the summer months, Professor Tiirck, of 
Vienna, endeavored to employ the laryngeal mirror in the wards of the 
General Hospital. 

In the month of November of the same year,* Professor Czermak, of 
Pesth, commenced to work with one of Dr. Tiirck's laryngeal mirrors, and 
in a short time he overcame all difficulties. Artificial light was substi- 
tuted for the uncertain rays of the sun, the large ophthalmoscopic mirror 
of Ruete was used for concentrating the luminous rays, and mirrors were 
made of different sizes. Thus it was that Garcia's re-invention of the 
laryngeal mirror led Czermak to create the art of laryngoscopy. 

The references, in nearly every section of this work, to medical practi- 
tioners in Europe and America, will afford evidence as to the great de- 
velopment of this new department of practical medicine in recent times. 

The laryngoscope is essentially the laryngeal mirror, but for practical 
purposes it may be said to consist of two parts: 1st, a small mirror fixed 
to a long slender shank, which is introduced to the back of the throat; 
and 2dly, an apparatus or arrangement for throwing a strong light (solar 
or artificial) on to the small mirror. 

The Laryngeal Mirror. — This may be made of polished steel, or of 
glass backed with amalgam. Though, on theoretical grounds, the steel 
mirrors give the more perfect image, they so readily become tarnished 
and rusty from the least moisture, are so immediately spoilt by acciden- 
tal contact with the medicated solutions used in treating laryngeal dis- 
ease, and so soon become scratched in cleaning, that they are not found 
convenient in practice. The glass mirror is generally mounted in Ger- 
man silver; for though the metal is too favorable to the rapid cooling of 
the mirror, and the consequent deposit of moisture upon it, it is more 
easy to fix the shank of the instrument to a frame of metal than to any 
other substance of inferior conducting power. The mtrrors should not 
be more than one-twentieth of an inch in thickness. 

The reflecting surface of the laryngeal mirror may vary from half an 
inch to an inch and a quarter in diameter. It is well to be provided with 
at least three mirrors, varying in size between the dimensions specified. 
The largest-sized mirror is called No. 1, the middle-sized one No. 2, and 
the smallest No. 3. 

For ordinary purposes, a No. 2 mirror will be found most convenient. 

1 It is worthy of note that Garcia never really followed this plan, but, in point of 
fact, always used a second mirror for throwing the solar rays on to the laryngeal mir- 
ror. In the mirror which he used as a reflector, he also saw the autoscopic image. 

2 Zeitschrift der Ges. der Aerzte zu Wien, April 26, 1858. 

3 Wien. Medizin. Wochenschrift, March, 1858: and Physiolog. Unters. mit Garcia's 
Kehlkopf spiegel, mit iii. Tafeln. Sitzber. der k.k. Akademie Wiss. in Wien, vom 
29 April, bd. xxix. p. 557. (Afterward reprinted in a separate form. ) 

11 



162 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

It may be of square, circular, or oval shape. The circular mirrors cause 
least irritation, except when enlarged tonsils are present, in which case 
the oval mirrors are most suitable. The shank of the mirror should be of 
German silver; it ought to be about four inches in length, and one-tenth 
of an inch in thickness, and should be soldered to the back of the mirror, so 
that the latter forms with it an angle of about 120 deg. The handle should 
be about three inches in length, and rather more than a quarter of an inch 
in thickness. The shank or stem of the mirror is sometimes, for the sake of 
portability, made to slide into a hollow wooden handle, and is fixed there 
by a screw, as is shown in the annexed drawing (Fig. 12, B). The little 
screw referred to is, however, apt to get loose, and if the stem is made 
movable, it should be screwed into the handle — the end of the stem 
itself forming the screw. It is better, perhaps, to have the stem im- 
movably fixed to the handle, as firmness is thereby ensured. 

Arrangements for Reflecting the Light. — For throwing a light on to 
the laryngeal mirror, and thus into the larynx, it will be found most 
convenient to employ a circular mirror about three inches and a half in 





Fig. 12. — The Laryngeal Mirror: A, diagram showing the exact sizes of the reflecting surface of the 
mirrors Nos. 1, 2, and 3 ; B, the mirror and holder (half-size) seen in profile. 

diameter, with a small hole in the centre. 1 "When artificial light or 
diffused daylight is employed, the mirror should be slightly concave, and 
have a focal distance of about fourteen inches; but when solar light is 
made use of, the surface of the mirror should be plane. The mirror may 
be attached in some way to the operator's head, or fixed to a horizontal 
arm, which is connected with the body of the lamp (Tobold). 2 The 
former plan is by far the most convenient, and the mirror may be worn 
either opposite one of the eyes (Czermak), 3 in front of the nose and mouth 
(Bruns), 4 or on the forehead (Fournie, 6 Johnson, 6 etc.). Of these positions, 
the first is, on theoretical grounds, the most perfect; the last the easiest 
in practice. The plan of looking through the hole of the reflector offers 
the great advantage of entirely protecting the observers eyes from the 
glare of the light ; for whilst the luminous rays necessarily fall obliquely 

1 The reflector should not merely be left unsilvered in the centre, but should be 
actually perforated ; otherwise the glass makes a slight focal inequality between the 
two eyes. Laryngoscopes, made in every respect according to my directions, are sold 
by Messrs. Mayer & Meltzer, 71 Great Portland Street. 

2 Laryngoscopie, etc., Berlin, 1874, p. 19. 3 Loc. cit. 
4 Die Laryngoscopie, Tubingen, 1873. 6 Loc. cit. 
6 Lectures on the Laryngoscope, 1864. 



THE LARYNGOSCOPE AND ITS ACCESSORY APPARATUS. 163 



on the mirror, and therefore do not reach the pupil of the eye immediately 
behind it, the other eye is also within the shadow of the reflector. It is 
only in the first position, moreover, that the observer can look through 
the hole in the reflector; if, 
therefore, either of the other 
methods is practised, the re- 
flector need not be perforated. 
The reflector may be attached 
to the operator's head, either by 
a spectacle-frame (Semeleder), 1 
or by a frontal band, as recom- 
mended by Kramer, and first 
employed by Bruns. 2 The spec- 
tacle-frame, with the upper 
halves of the rim removed (as 
seen in Fig. 13), is the arrange- 
ment which I have found most 
convenient. In either case the 
mirror should be connected with 
its support by a ball-and-socket 
joint. The hole in the centre 
of the reflector should be ob- 
long, and when placed in front 
of the eye, its long diameter 

should correspond with the long diameter of the eye. A hole of this shape 
allows for the varying distance between the nose and eyes in different 
people, and for the varying position of the centre of the reflector, in its 




\i^ 



Fig. 13.— Reflector attached to spectacle-frame, from 
which the upper halves of the rims have been removed. At 
the back of the reflector (i?) is a small cup, into which a 
ball connected with the spectacle-frame fits. A ring is 
screwed oyer the ball, and the joint is thus formed at (J). 




Fig. 14.— The Author's Rack -Movement Lamp, 
hole being left where the lens fits in. 



The chimney of the lamp is made of metal, a round 



different degrees of inclination. Practitioners who labor under defective 
vision will find it convenient to have suitable glasses fitted to the spec- 
tacle-frame of the frontal reflector. 

Illumination. — Any lamp that gives a bright steady light answers the 
purpose perfectly well. Many of the most valuable observations have 
been made with a common ""moderator." An argand gas-burner will be 
found very convenient, especially if constructed on the reading-lamp 
principle, so that it can be fixed at different heights. My rack -movement 



1 Die Laryngoscopie, etc., Wien, 1863, p. 13. 



2 Loc. cit. p. 22. 



164 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

laryngoscopy lamp, which readily admits of perpendicular and horizontal 
movement, will be found to greatly facilitate the management of the 
light. Its action is shown in Fig. 14. The power of the light is increased 
by a lens placed in front ftf the flame. My lamp is now used in nearly 
every hospital in this country where laryngoscopy is systematically em- 
ployed. 

For use at the bedside, where gas is not at hand, my new clinical 
lamp will be found very serviceable. It has the same action as the rack- 
movement lamp, but paraffin is used for illumination instead of gas. It 
makes a very useful lamp for the consulting-room. By reference to the 
wood-cut (Fig. 15), it will be seen that the base of the" apparatus can be 
hooked on to the bar of a bed, and that the perpendicular stem rotates,. 




Fig. 15. — The Clinical Lamp. In the illustration, the lamp is seen hooked on to the horizontal bar of 
a bed ; the dotted lines show the position of the base when the lamp is standing on a table. 

so as to adapt itself to this position. On the other hand, when in use on 
the table, the stem can be easily adapted to the upright position, by means 
of the screw at its foot. 

In the various lamps or lanterns recommended by different foreign 
laryngoscopists (Tobold, 1 Moura-Bourouillou, 2 etc., etc.), the arrangement 
of lenses in each of them is only applicable to the particular lamp for 
which it was contrived. This serious objection to the various kinds of 
illuminating apparatus hitherto in vogue, led me to contrive a light-con- 
centrator of more extensive application. It not only gives a very brilliant 
light, but is at the same time much smaller, and therefore much more 
portable than any of those hitherto in use, and it can be employed with 
any kind of lamp, or even a candle. It consists of a small metal cylin- 
der, three and a half inches long, and two and a half in diameter. This 
is closed at one end, and at the other there is a plano-convex lens, the 
plane surface of which is next the flame. The lens is two and a half 
inches in diameter, and is about one-third of a sphere. In the upper and 
under surfaces of the cylinder (opposite each other) are two round aper- 
tures, two inches and a quarter in diameter. These holes are not equi- 
distant from the two ends of the tube, but so near to the closed extremity 
that a line passing perpendicularly through their centres would be about 

1 Loc. cit. p. 19. 2 Traite pratique de laryngoscopie, etc., Paris, 1864. 



THE LARYNGOSCOPE AND ITS ACCESSORY APPARATUS. 



165 



two inches and a half from the plane surface of the lens, and rays of light 
pass through in comparatively parallel directions. At the lower part of 
the tube are two semicircular arms, which, by means of a screw at the 
side, can be made to grasp tightly the largest lamp-chimney, an ordinary 
candle, or even the narrow stem of a single gas-jet. The practitioner, 
therefore, who, in visiting patients, carries my light-concentrator, can 
always feel certain of being able to illuminate the fauces. The apparatus 
is passed over the chimney, till the centre of the lens is opposite the most 
brilliant part of the flame, and then, by 
a few turns of the screw, the concentra- 
tor is fixed in position. When a candle 
is employed, the flame is in the centre 
of the tube. 

In the side of the tube near the lens 
are two ivory knobs covered with cork, 
which enable the practitioner to hold 
the concentrator and remove it from the 
lamp, even when it is extremely hot. 
For the consulting-room the light-con- 
centrator may be most advantageously 
employed either with an argand gas-bur- 
ner, a paraffin, moderator, or reading 
lamp. The latter kind of lamp, with an 
argand gas-burner, will be found conve- 
nient, though my rack-movement laryn- 
goscopy lamp is the best that can be 
employed. 

The light of a candle, strengthened 
by this concentrator, will be found to 
«qual that given by an ordinary lamp. 
"When the practitioner has only a centre 
gaselier at his command, the light-con- 
centrator should be applied to the only 
jet which is lighted; and as it is not generally possible to pull a gaselier 
sufficiently low down to make the examination in the ordinary way, under 
these circumstances both patient and practitioner must stand upright. 

Besides the concentrator just described, I have had a smaller illumin- 
ating apparatus constructed, which is called my " miniature light-concen- 
trator." The principle is the same in both; but in the latter the metal 
cylinder is only two inches in length, and an inch and a half in diameter: 
it is only suited for the small paraffin lamp, which is sold with it. This 
lamp, which measures only four inches from its foot to the top of the 
■chimney, is like a little vial, and has a metal screw stopper, so that it can 
be carried about with safety. 

It has been already observed that the employment of a reflector is not 
•absolutely necessary for throwing a light on to the laryngeal mirror. 
The solar rays, or diffused light, on a bright day, may be concentrated on 
the laryngeal mirror. In the former case, the surface of the reflector 
must be plane ; in the latter, the usual concave mirror may be used. The 
patient should sit with his back turned obliquely to the window, and the 
practitioner opposite him. The sunlight in this way passes over the pa- 
tient's shoulder to the reflector, and is thence projected on to the laryn- 
geal mirror. In other respects the examination is conducted in the same 
•way as when artificial light is used. 




Fig. 16. — The Light-Concentrator. In the 
drawing, the concentrator is fixed on to a can- 
dle by means of two arms (a). In using a lamp, 
the arms embrace the chimney : a, screw for 
tightening the arms ; b, one of the cork knobs 
for taking hold of the concentrator when hot. 



166 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



"When the observer does not make use of a reflector, the rays of light 
must be thrown from a lamp directly into the patient's mouth, or else the 
luminous rays must be projected from a light in less close proximity by 
a lens placed in front of the flame. In using an ordinary lamp for direct 
illumination, either a common plano-convex lens may be used, or a large 
glass globe about six inches in diameter, filled with water. The latter 
kind of concentrator (the so-called Schusterkugel) was first recommended 
by Tiirck, 1 and afterward adopted by Stoerk; but, whilst the former 
soon abandoned its use in favor of the reflector, the latter still employs it 
almost invariably. This apparatus has been further improved by Dr. 
Walker, of Peterborough. It gives a brilliant light, which is most in- 
tense at about twenty inches from the globe. As it is quite impossible 
to carry this enormous glass globe about, its use is necessarily confined 
to the practitioner's consulting-room. 

A much more convenient plan is that adopted by several of the French 
physicians, which may be thus described: A lamp provided with a lens 
is placed on a table so narrow, that the laryngeal mirror can be used by 
the practitioner on a patient sitting on the opposite side of the table. A 
shade screens the light from the observer's eyes, whose face, in this mode 
of examination, is close to the lamp. In applying remedies, the lamp is 
between the arms of the practitioner, who, as it were, embraces it. Dr. 
Fauvel, of Paris, uses a table about three feet 
long and one foot broad, in three leaves; the 
centre leaf, on which a moderator lamp rests, can 
be screwed up and down to different heights for 
different patients. Dr. Krishaber 2 employs a sim- 
ple round table of small dimensions. 

For direct illumination the oxy-hydrogen lime 
light is by far the best that has yet been invented,, 
and is especially adapted for demonstrations of 
cases to a number of persons. Not only is the 
light superb, but the mode of illuminating is much 
less fatiguing to the operator when a large num- 
ber of cases have to be seen, and the heat, if not 
actually less, is less felt on account 
further removed from him. 1 

Magnifying Instruments. — Various instru- 
ments have been invented for increasing the size 
of the laryngeal image, but they are of no use in 
the treatment of disease. As early as 1859, Dr. 
Wertheim, of Vienna, recommended concave la- 
ryngeal mirrors for this purpose; and later, Dr. 
Tiirck, 4 calling attention to the fact that the la- 
ryngeal image is made up of a number of parts 
suggested the use of a small telescope which he 
Finallv, Voltolini 5 made some 




of its being 



Fig. 17.— The Head-rest. 



at different distances 

had fitted to his illuminating apparatus. 

further improvements in the apparatus. 



1 Zeitschrift der Gesellschaft der Aerzte, Nro. 8, 1859, und Allgem. Wien. Med. 
Zeitung, Nro. 15, 1859. 

3 Diet. Encyclop. des Sciences Medicales, Paris. 1868. 

3 A full description and illustration of this method of illumination will be found in 
my work on The Laryngoscope, 3d edition, p. 46. 

4 Klinik der Krankheiten des Kehlkopfs, etc., p. 137, Wien, 1866. 

5 Galvano caustik, p. 93. 



THE LARYNGOSCOPE AND ITS ACCESSORY APPARATUS. 167 



Micrometers. — For measuring the exact size of different parts of the 
larynx, and for estimating- distances, Merkel, 1 of Leipzig, and Mandl, 2 of 
Paris, have suggested the plan of having a scale scratched on the laryn- 
geal mirror. Dr. Semeleder s objected to this mode of measuring, as it 
takes so much away from the reflecting surface of the mirror, and recom- 
mended that the scale should be drawn on the frame of the mirror. Though 
these scales might, perhaps, be advantageously employed for physiologi- 
cal investigations, they are of no use to the medical practitioner. 

Laryngoscopy Chairs, Head-rests, etc. — Most people, when they are 
about to have the throat examined, lean back in. the chair, throw up the 
head, and open the mouth. This attitude, however, is very ill suited for 
laryngoscopy, where both 
the head and body should 
be kept erect. In many 
cases also — especially where 
the patient is at all nervous 
— in applying remedies to, 
or operating on, the larynx, 
it is very desirable to be 
able to steady the head. I 
now use in private practice a 
narrow-seated high-backed 
chair (Fig. 21). The seat 
measures only a foot in 
depth, and the back is 
thirty -four inches high. 
This kind of chair obliges 
the patient to sit upright, 
and greatly assists in stead- 
ying the head. I formerly 
employed a head-rest (Fig. 
17), very much like that em- 
ployed by photographers, 
except that instead of hav- 
ing a stand of its own, it 
is fixed to an ordinary chair. 
A strong metal plate, ter- 
minating in a ring; behind, 
is screwed to the under sur- 
face of the frame which sup- 
ports the seat; and another 
similar projecting ring is 
screwed to the top bar of 
the chair. A strong iron 
bar passes perpendicularly 
through these rings; just 
above the upper ring it 

bends obliquely forward for about half a foot, and then again passes per- 
pendicularly upward for another foot. This bend in the bar prevents the 
patient leaning back. Sliding on the perpendicular bar, is a broad, curved, 
semicircular pad, which supports the head, and can be fixed at any height. 

1 Die Funktionen des menschlichen Schlund — u. Kehlkopfes, p. 5, Leipzig. 1862. 
'Traite pratique des Maladies du Larynx, etc., p. 115, Paris, 1872. 
3 Loc. cit. p. 27. 




Fig. 18. — Laryngoscopy Chair, especially adapted for hospi- 
tal purposes. At a a lever of the second kind is brought into play 
through b and c, the fulcrum being at x. By pressing on the 
handle a, the patient is at once raised to the desired elevation. 
On the other hand, by pressing on d with the foot, the operator 
withdraws the bolt/ from the rack z. and the chair gradually de- 
scends. There is a narrow back-board (g) with a movable head- 
rest (A), which slides up and down the groove (i), and can be 
fixed at any height by a screw at the back. 



168 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

It allows the patient to raise his head, but prevents any movement back, 
ward or laterally. The apparatus is not unsightly, if the metal part is 
made of brass; and when the support is not required, the perpendicular 
bar and head-rest can be altogether put away. 

For hospital practice, and especially when the oxy-hydrogen light is 
used, the laryngoscopic chair represented in Fig. 18 will be found the 
most convenient. It enables the operator to raise or lower the patient 
without rising from his seat. 



LARYNGOSCOPY. 




The only principle concerned in the art of laryngoscopy is the optical 
law, that when rays of light fall on a plane surface, the angle of reflection 
is equal to the angle of incidence. A small mirror is placed at the back 
of the throat, at such an inclination that luminous rays falling on it are 
projected into the cavity of the larynx; at the same time the image of 
the interior of the larynx (lighted up by the luminous rays) is formed on 
the mirTor, and seen by the observer. The mirror is held obliquely, so 
that it forms an angle of rather more than 45° with the horizon. The 

plane of the laryngeal aperture 

(bounded by the epiglottis, the 

:;::.:::::::::--.":-—- ::: " nn *"' < ' ary-epiglottic folds, and the aryte- 
noid cartilages), is also oblique, the 
epiglottis being higher than the 
apex of the arytenoid cartilage. 

The annexed diagram shows 
the position of the different parts, 
and explains their reflection. Let 
Fig. 19.-Diagram showing the relative positions m represent the plane of the laryn- 

of the planes of the larynx and laryngeal aperture. geal mirror, I the plane of the up- 

per opening of the larynx, and o 
the observer. In the plane of the larynx, a represents the arytenoid carti- 
lages, aethe ary-epiglottic folds, and e the epiglottis; the rays from these 
parts impinge on the mirror, as d, ae, and e, and are thence reflected to the 
observer at o. Thus the epiglottis, which is really the highest in the throat, 
appears at the upper part of the mirror, the ary-epiglottic folds appear 
rather lower and at each side of the mirror, whilst at the lower part of 
the mirror are the arytenoid cartilages. These remarks apply to the ver- 
tical reflection. 

The only inversion which takes place in the formation of the image 
is in the antero-posterior direction; the part which in reality is nearest to 
the observer, the anterior commissure of the vocal cords (etc in B, Fig. 
20), becomes furthest in the image (etc in A, Fig. 17), and the posterior 
commissure, pc, which, in reality, is farthest from the observer, becomes 
nearest in the image. 1 The symmetrical character of the image, which 
makes it impossible to judge of right and left, and this antero-posterior 

1 This is in accordance with the fundamental optical law : That if a diverging 
pencil of light fall upon a plane reflecting surface, the focus of the reflected pencil will 
be at the same distance from the surface as that of the incident pencil, but on the oppo- 
site side of it. 



LARYNGOSCOPY. 



169 



inversion which actually takes place, often leads people to form erroneous 
•opinions concerning the two sides of the larynx. 

The lateral relation of parts in the image must now be considered. 
The mirror being placed above and behind the laryngeal aperture; the 
rays of light proceeding from the larynx pass directly upward and back* 
ward, and the patient's right vocal cord is seen on the left side of the 
mirror, and the left vocal cord on the right side of the mirror (just as the 
patient's right hand is opposite the observer's left, and his left hand oppo- 
site the observer's right). In the annexed cut (Fig. 20), a wart is seen 




F e 




1 



Fig. 20.— Drawing showing the Relation of Parts in the Larynx (B), and the Laryngeal Mirror (A) : ac, 
interior commissure of the vocal cords ; pc, posterior commissure of the vocal cords ; r, right vocal cord ; 
2, left vocal cord, with a wart on it. 



on the left vocal cord of the larynx (B); this is opposite the observer's 
right hand, and it appears on the same side in the image (A). In conse- 
quence, however, of the antero-posterior inversion which takes place as 
explained in the last paragraph, if the fact that the representation of the 
larynx (A) is an image is not borne in mind, it would lead to the decep- 
tive idea that the wart was on the right vocal cord. In examining a 
laryngoscopic drawing, a person must not make his own larynx the men- 
tal standard of comparison as regards right and left, but must recollect 
that the picture represents an image formed on a mirror held obliquely 
above and rather behind the larynx of another person. 



170 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

In making a larvngoscopic examination there are three stages. 

First Stage. — The patient should sit upright, facing the observer, with 
his head inclined very slightly backward. The observer's eyes should be 
about one foot distant from the patient's mouth, and a lamp burning with 
a strong clear light should be placed on a table at the side of the patient, 
the flame of the lamp being on a level with the patient's eves. The ob- 
server should now put on the spectacle-frame with the reflector attached, 
and directing the patient to open his mouth widely, should endeavor to 
throw a disk of light on to the fauces, so that the centre of the disk corre- 
sponds with the base of the uvula. If the observer has much trouble in 
projecting the light on to the fauces, he will find it convenient to incline 




Pig. 21.— Laryngoscopy — Third Stage, showing position of practitioner and patient. 



the reflector at a suitable angle before putting on the spectacle-frame. 
This may be done as follows: Taking the spectacle-frame in the hand, 
with the mirror attached, so that the central aperture in it would come 
opposite to the pupil of the operator's right eye, and fixing the joint so 
that the back of the mirror is parallel with the spectacle-frame, the outer 
edge of the reflector should be pushed rather more than a quarter of an 
inch forward or backward, according as the lamp is on the right or left 
side of the patient. If the observer has chosen his position and placed 
the lamp as directed, on putting on the spectacle-frame, a beautiful lumi- 



LARYNGOSCOPY. 



171 



nous disk will appear at the back of the throat. When direct light is 
used, the first stage is much simplified, as the patient has only to sit op- 
posite the lens of the lamp, as described at page 1G5. 

Second Stage. — The patient should be directed to put out his tongue, 
and the observer should hold the protruded organ gently but firmly be- 
tween the finger and thumb of his left hand, the thumb being above and 
the finger below. To prevent the tongue slipping, the observer's hand 




Fig. 22.— Diagram showing the Angles of Incidence aud Reflection in Ordinary, and Infra-glottic,. 
Laryngoscopy : A, side view of mirror, when properly introduced. It is seen to push back the uvula toward 
the posterior nares. B, side view of infra-glottic mirror ; C, left vocal cord. 



should be previously enveloped in a small soft cloth or towel, and h& 
should be careful to keep his finger rather above the level of the teeth, 
in order that the frasnum may not be torn. The position of the practi- 
tioner and patient is shown in Fig. 21. In cases that are likely to re- 
quire local treatment, the patient should be taught to hold out his own 
tongue, so that the operator may be able to introduce the mirror with 
his left hand, whilst with the right he applies the remedy to the affected 
part. 



172 



DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 




FIG. 23.— The Position of the Hand and Mir- 
ror, when the latter has been properly introduced 
for obtaining a view of the larynx. 



Third Stage. — When the observer has practised the first two stages, 
he should take a small laryngeal mirror about half an inch in diameter, 
and after warming its reflected surface for a few seconds over the chimney 
of the lamp (to prevent the moisture of the expired air being condensed 
on it), should introduce it to the back of the throat. In holding a mirror 
over a lamp, the little glass is first covered with a film of moisture, which 

quickly clears away. Directly the 
glass is clear, it is the right tempera- 
ture — neither too hot nor too cold 
— to be introduced. Before intro- 
ducing the mirror, however, lest it 
should be accidentally too hot, the 
practitioner should test its tempera- 
ture by placing it on the back of his 
hand. Supposing that the various 
steps already described have been 
followed, and that there is a steady 
disk of light on the base of the uvula, 
the laryngeal mirror should now be 
introduced ; but no attempt should 
ever be made unless perfect illumi- 
nation has first been effected. To 
pass the mirror to the back of the 
throat with as little annoyance as 
possible to the patient, the following 
method should be adopted : The 
handle of the mirror should be held 
like a pen in the right hand, and quickly introduced to the back of the 
throat, its face being directed downward, and kept as far as possible from 
the tongue in the median line of the mouth (Fig. 23). The posterior 
surface of the mirror should rest on the uvula, which should be pushed 
rather upward and backward, toward the posterior nares (Fig. 22). 
When the mirror has thus been introduced without irritating the fauces, 
the observer should raise his hand slightly and direct it outward toward 
the corner of the mouth. This rotatory movement, which alters the in- 
clination of the mirror, and turns its face more toward the perpendicu- 
lar (whilst the hand is thereby kept entirely out of the line of vision), 
should be effected rather slowly, so that it can be arrested directly the 
larynx comes into view. After introducing the mirror, the observer 
■can, if he chooses, steady it, by resting the third and fourth fingers 
against the patient's cheek. The exact angle which the mirror should 
bear to the laryngeal aperture must depend on a number of circumstances, 
such as the degree of flexion backward of the patient's head ; the particu- 
lar angle which the plane of the laryngeal aperture bears to the horizon 
in the case undergoing inspection ; and on the direction which the ray 
must take to reach the observer's eye — that is to say, on the position of 
the observer (Fig. 23). The practitioner should learn to introduce the 
mirror with either hand, for by so doing any false ideas concerning a 
supposed asymmetrical condition will be at once corrected ; and whilst, 
for the purpose of diagnosis, it is very desirable to be able to use either 
hand, in the application of remedies to the larynx, ambidexterity is abso- 
lutely essential. 

Beginners, in their anxiety to get a good view, often give rise to fau- 
cial irritation, by keeping the mirror too long in the patient's mouth ; 



LARYNGOSCOPY. 173 

but one of the commonest mistakes made by those unpractised in the use 
of the laryngoscope, consists in introducing the laryngeal mirror before 
the disk of light has been steadily concentrated on the base of the uvula. 
The imperfect illumination causes the operator to touch the back of the 
throat in several places before it is put on the right spot. Again, begin- 
ners often lose the light, even after they have thrown the rays in the 
first instance in the proper direction ; under these circumstances, in- 
stead of withdrawing the laryngeal mirror and redirecting the light on to 
the centre of the fauces, as the skilled laryngoscopist would do, the be- 
ginner moves his head (which supports the frontal mirror) in the hope 
of thus being able to throw the light in the right place, the laryngeal 
mirror being kept in the meantime in the patient's throat, where it is 
certain to cause irritation. This is a fatal error. The practitioner 
should recollect that when an act of retching has once taken place, it 
is afterward often impossible to get a good view of the larynx at the 
same sitting. Moreover, the act of retching always causes consider- 
able temporary congestion of the laryngeal mucous membrane, and thus 
is apt to lead the inexperienced to very erroneous conclusions. It is, 
therefore, better to introduce the mirror any number of times, keeping 
it in the throat only for a few seconds each time, than to let it remain 
longer, and thus limit the examination to one inspection. The novice 
must be careful to avoid touching the tongue with the mirror, for this 
procedure irritates the throat, and spoils the reflecting surface of the mir- 
ror for the time. This can generally be avoided by keeping the back of 
the mirror in close proximity to, but not letting it touch, the palate. In 
some people, however, the uvula is in actual contact with the back of the 
tongue, and as in inspiration or vocalization the uvula is raised, such per- 
sons should be directed to inspire deeply, or to produce some vocal sound 
(such as " ah," "eh," "oh," etc.) ; the mirror can then be easily slipped 
in between the uvula and the tongue. All violence or even roughness 
must be carefully avoided, the tongue must be held out most gently, and 
the laryngeal mirror placed very lightly on the uvula. Complicated in- 
struments for holding the mouth open almost invariably lead to failure. 

Special Difficulties. — The difficulties solely dependent on the practi- 
tioner's want of dexterity have been already considered, but a few words 
must be devoted to those in part due to the patient. The obstacle may be 
either undue irritability of the fauces, a peculiar action of the tongue, an 
abnormal size of the tonsils, or a pendent condition of the epiglottis. 

As regards faucial irritability, it is to be observed that though this 
condition sometimes exists of itself, it is far more often caused by the 
clumsiness or inexperience of the practitioner. Most patients can be ex- 
amined with facility at the first sitting, and only a small proportion re- 
quire any training. With timid patients — especially women — on first 
using the laryngoscope, it is well to place the mirror for a second on the 
back part of the palate, without being too particular about seeing any- 
thing. By introducing the mirror once or twice in this way, the patient's 
confidence is secured, and a more fruitful examination may afterward be 
made. For reducing an unusually irritable condition of the fauces, we 
may have recourse to several expedients, in order to enable the patient to 
tolerate the introduction of the laryngeal mirror. Bromide of potassium 
is generally supposed to have the power of producing anaesthesia of the 
pharynx, but the effects of this drug are tt>o uncertain to meet the wants 
of the laryngoscopist. The method of frequently painting the mucous 
membrane with chloroform, ether, or solution of morphia, recommended 



174 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

by Tiirck ' and Schroetter, 2 is tedious and attended with the danger of 
producing serious general narcotism. Von Bruns 3 advises that the pharynx 
should be sprayed with a solution of tannin, or pencilled with a mixture 
of tannin and glycerine. When, however, the practitioner requires to 
make an immediate inspection of the larynx, his object may almost always 
be accomplished by directing the patient to suck small pieces of ice con- 
tinuously for fifteen or twenty minutes. This remedy rarely, if ever, fails 
to blunt for a short time the ordinary sensitiveness of the mucous mem- 
brane. In cases where it is necessary to carry out a prolonged local treat- 
ment of the larynx, as in the removal of growths, the patient may be di- 
rected to practise on himself daily with the laryngeal mirror. 

The conformation of parts occasionally causes some difficulty. Thus, 
when the tongue is drawn out, it sometimes forms an arched prominence 
behind, which causes trouble in introducing the mirror, and difficulty in 
seeing it when in situ. This position of the tongue is due to reflex action, 
and will be best avoided by pulling the tongue less forward than usual, 
keeping it level with the mouth (that is to say, not holding it down to- 
ward the chin), and by cautioning the patient not to strain. 

Enlarged tonsils sometimes embarrass the operator. In this condition 
a small oval mirror should be used. An unusually large or pendent epi- 
glottis causes a more serious impediment to laryngoscopy. When the 
valve is very large, it sometimes shuts out the view of the larynx ; but 
the same result is more often caused by unusual length or relaxation of 
the glosso-epiglottic ligaments. In the production of high (falsetto) 
notes, the epiglottis is generally raised, and this also happens when a per- 
son laughs; the observer will, therefore, do well to take advantage of these 
physiological facts. In a certain number of cases, however, the epiglottis 
remains obstinately pendent. For elevating the valve in these cases, va- 
rious instruments have been invented, but they seldom prove of any ser- 
vice. Some of the German laryngoscopists recommend that a thread 
should be passed with a curved needle through the epiglottis. An assist- 
ant, standing behind the patient, draws the thread over the patient's face 
and head, or the opposite end of the thread may be tied round the pa- 
tient's ears. Most of the instruments hitherto invented, however, cause 
so much irritation that they cannot often be employed with advantage. 4 
When the epiglottis covers the larynx in the manner described, the laryn- 
geal mirror should be introduced lower in the fauces, and more perpen- 
dicularly than is usually suitable. In almost all cases the arytenoid carti- 
lages, surmounted by the capitula Santorini, can be seen, and from them 
we can judge with tolerable certainty as to the mobility of the vocal cords; 
the state of the mucous membraneof the larynx in other parts cannot, 
however, be safely inferred from the condition of that which covers the 
arytenoid cartilages. 

1 Klimk der Krankheiten des Kehlkopfs, Wien, 1866, p. 551 et seq. 

2 Jahresbericht, etc. (op. cit.), 1870, p. 34. 

3 Die Laryngosk. u. die Larvngosk. Chirurgie, Tubingen, 1865, p. 53. 

4 See Tiirck : Klinik der Kehlkopfskrankheiten, Wien, 1866, p. 551 et seq. ; Tobold : 
Laryngoscopie, Berlin, 1874, p. 449 et seq. ; Oertel : Deutsches Archiv fur klin. Medi- 
-cin, vol. xv., Heft 3 and 4; and my work on The Laryngoscope, Third edition, p. 85. 



I/ARYNGOSCOPY. 175 



Auto-Laryngoscopy. 



Those who desire to acquire dexterity in introducing the mirror at 
their own expense, rather than that of their patients, and those who wish 
to demonstrate their larynx to others, should learn to employ the laryn-' 
goscope on themselves. 

When auto-laryngoscopy is practised, it is requisite that, besides the 
circular reflector and laryngeal mirror, another mirror should be used: 
this must be placed in such a position that the image reflected in it from 
the throat-mirror can be seen by the autoscopist. For practising auto- 
laryngoscopy, Professor Czermak ' contrived a special apparatus. It has 
a large reflector and quadrilateral mirror, each supported on perpendicular 
bars. These mirrors are fixed about a foot apart, and both can be turned 
in almost any direction, and fixed at any height. In using this apparatus, 
the observer should sit at a table with the quadrilateral mirror a few inches 
in front of his mouth, and the reflector a foot further back, the upper edge 
■of the square mirror being level with the lower edge of the reflector be- 
hind it. The flame of the lamp should be near, but a little behind and to 
the side of, the quadrilateral mirror. The observer now throws the light 
into his fauces with the reflector, introduces the warmed laryngeal mirror, 
and sees the image in the quadrilateral glass. People facing the demon- 
strator can see the image in the laryngeal mirror, and those behind him 
in the one which he looks at. For those who wish to make accurate phy- 
siological observations, this is the best method of practising auto-laryn- 
goscopy. Those who object to purchase a special apparatus can use the 
ordinary reflector for auto-laryngoscopy. In this case, all that is requisite 
is a perpendicular telescope-bar, capable of being made about a foot and 
a half in length, and having a broad firm base: at the top of the bar is a 
small projecting ball, which fits into the socket at the back of the ordinary 
reflector. The reflector is placed on a table, at about eighteen inches from 
the observer, between whom and the reflector there must be a small toilet 
mirror or hand-glass. In other respects, the examination must be conduct- 
ed as already described. 

A simpler method of practising auto-laryngoscopy is that recommended 
by Dr. George Johnson. 2 The observer puts on his ordinary reflector, as 
though he were going to examine a patient, and sits facing a toilet mirror. 
A lamp is placed on one side of the observer, in a line with the mirror, or 
slightly behind it, and by manipulating the reflector the observer now 
throws the light on to the image of his fauces, as seen in the toilet -glass. 
He then introduces the laryngeal mirror into his throat, and the image of 
the larynx formed on it is seen in the toilet-glass, both by the demonstra- 
tor and by the persons standing behind him. In practising auto-laryngo- 
scopy in this manner, the practitioner has to manage the light in the same 
way as in examining patients, and he thus learns to overcome one of the 
difficulties of laryngoscopy. The only disadvantage of this method, as 
compared with that of Czermak, is that, by it, the rays of light undergo 
an additional reflection before they reach the larynx, and thus the image 
is not quite so distinct. 

1 Loc. cit., pp. 1 and 28 (with illustration). 2 Loc. cit 



176 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



Infra-glottic Laryngoscopy. 

"Where tracheotomy has been performed, and a fenestrated canula is- 
worn, a very minute mirror may be introduced through the tube with its 
face directed upward; or the canula may be removed, and the mirror 
passed into the wound (Fig. 22, p. 171). In this way the observer obtains 
a view of the larynx from below. 

This method was first suggested by Dr. Neudorfer, 1 in 1858, and was 
first carried out by Professor Czermak 2 in the following year. Since then, 
various observers have examined patients in this way, and I have myself 
often had the opportunity of employing the mirror from below. Some 
interesting observations made by a medical man on himself have been re- 
corded by Dr. Semeleder. 8 This mode of examining the larynx, though 
of very limited application, is valuable, because it generally happens, in 
cases where a canula is worn, and air is inspired mainly through the tra- 
chea, that the epiglottis does not rise up, but remains pendent, in inspira- 
tion; in post-tracheotomy cases, also, it often happens that the epiglottis 
is bound down over the larynx by old cicatrices, and consequently ordi- 
nary laryngoscopy is useless. It is well to remark that the vocal cords, 
when observed from below, have a reddish color, and do not present the 
peculiar white appearance which is seen when the laryngeal mirror is placed 
on the uvula. 



THE LARYNGEAL IMAGE. 

The rationale of the formation of the image having already been ex- 
plained (page 168), the special description of its individual parts will 
be now undertaken. In some cases, on introducing the laryngeal mirror, 
only the epiglottis may be visible, with perhaps just the tips of the capi- 
tula Santorini at the posterior part; whilst in others, the entire length of 
the vocal cords, the ventricular bands, the small cartilages of Wrisberg- 
and Santorini, a portion of the cricoid cartilage, the rings of the trachea, 
and perhaps even the bifurcation of the bronchi below it, can be seen 
with perfect distinctness. The view varies in different cases between 
these two extremes. 

The epiglottis varies very much in appearance in different individuals. 
In some cases it is broad, whilst in others it is extremely narrow; in some 
only the upper surface can be seen, in others, where the epiglottis is 
drawn tightly to the tongue, only the under surface is visible. In the 
centre of the free edge is a slight notch, which gives to the epiglottis, 
when seen in its entirety, its foliate appearance. But the free edge of 
the valve is more often turned upon itself, so that in the reflection the 
notch is lost sight of, and the border appears round. In some cases, on 
account of the inclination of the epiglottis, only the profile of its free 
edge is visible in the mirror. In these cases the valve is represented by 
a thin line. As a rule, there is seen (Figs. 24 and 25) — 1st, A portion of 
its upper surface on either side (u); 2dly, its free edge and a small por- 
tion of its under surface turned up in the centre, and forming a kind of. 

1 Oesterreich. Zeitschrift fur pract. Heilkutide, 1858, Nro. 46. 

2 Wiener Med. Wochenschrift, 1859, Nro. 11. 3 Loc. cit. p. 21 



THE LARYNGEAL IMAGE. 



177 



lip (I) ; and 3dly, another portion of its under surface, below and behind 
the lip, projecting as a rounded prominence — the cushion (c). The upper 
surface is of a dull pinkish hue; the lip is of a decided yellow color, 
though it has a slight shade of pink; and the cushion is invariably bright 
red. In some cases the whole of the under surface of the epiglottis is 
seen, and then it is of a bright red color. This normal coloration of the 
under surface of the epiglottis is apt to be mistaken (by those unaccus- 
tomed to the use of the laryngoscope) for congestion of the mucous mem- 
brane. Above the epiglottis, the glosso-epiglottic folds (ge) maybe seen, 
passing upward and backward to the tongue, the posterior superior bor- 
der of which appears as a horizontal uneven line. 

The ary -epiglottic folds (ae) which form the lateral boundaries of the 
upper laryngeal aperture, can be seen in the mirror extending obliquely 
downward and backward from the epiglottis to the arytenoid cartilages. 
Near the latter are the slight pinkish prominences of the cartilages of 
Wrisberg (c W), and a little beyond the cartilages of Wrisberg, in the 
same fold of mucous membrane, are two other small prominences, the 
capitula Santorini (c/S), surmounting the arytenoid cartilages. 



ft 




f< 



sp 






cS' a 



Fig. 25. 



Pig. 24.— Laryngoscopy Drawing, showing the Vocal Cords drawn widely apart, and the Position of the 
various Parts Above and Below the Glottis, during Quiet Inspiration : ge, glosso-epiglottic folds ; u, 
upper surface of epiglottis ; I, lip of epiglottis ; c, cushion of epiglottis ; v, ventricle of larynx ; ae, 
ary-epiglottic fold; cW, cartilage of Wrisberg; cS, capitulum Santorini; com, arytenoid commissure; 
Cc, vocal cord ; vb, ventricular band ; pv, processus vocalis ; cr, cricoid cartilage ; t, rings of trachea. 

Pig. 25.— Laryngoscopy Drawing, showing the Approximation of the Vocal Cords, and the Position of 
the various Parts in the Act of Vocalization : fi, fossa innominata ; sp, sinus pyrif ormis ; ch, cornu of 
hyoid bone ; c IF, cartilage of Wrisberg ; cS, capitulum Santorini ; a, arytenoid cartilages ; com, arytenoid 
commissure ; pv. processus vocalis. 



The cartilages of Wrisberg generally appear round, but sometimes, 
especially in thin people, they have a triangular shape — the apex of the 
triangle being directed outward. The capitula Santorini have a round- 
ish shape in the healthy larynx, and like the cartilages of Wrisberg are 
most distinct when the vocal cords are approximated. But the clearness 
with which these small laryngeal cartilages can be seen, depends also upon 
their degree of development, and upon the amount of submucous areolar 
tissue surrounding them; sometimes the cartilage of Wrisberg is not to 
be seen at all, whilst occasionally there is a small cartilage between it and 
the capitulum Santorini. The breadth of the ary-epiglottic folds varies 
in different people and in different states of the larynx, being greater 
when they are relaxed, that is, in inspiration, and narrow when they are 
tense, as in the approximation of the cords — especially in the production 
of high notes. The ary-epiglottic folds have been well described by 
Stoerk, as having almost the same color as the spurns. The cartilages of 
Wrisberg and Santorini are of a rather brighter and deeper color than 
the rest of the mucous membrane. 
12 



178 

The arytenoid cartilages (a) are easily recognized by the small carti- 
lages of Santorini which surmount them. They can be best seen when 
the vocal cords are approximated. The mucous membrane covering them 
is generally of a rather redder tinge than that forming the ary- epiglottic 
folds. Between the arytenoid cartilages is a fold of mucous membrane, 
the inter-arytenoid fold or commissure, which is most apparent when the 
glottis is widely open (Fig. 24, com); when the arytenoid cartilages are 
approximated, the commissure folds together, and is directed backward 
(Fig. 25, com). It is of a yellowish pink color. 

The ventricular bands (vb), formerly called the false vocal cords, are 
the folds of mucous membrane which are seen below the ary-epiglottic 
folds, passing obliquely in the antero-posterior diameter of the larynx, 
from the arytenoid cartilages to the epiglottis. They are thick, rather 
prominent, and of a deeper red color than the ary-epiglottic folds. Being 
rather thinner, and more prominent at their lower edge (which borders 
on the ventricle) than elsewhere, this part has a lighter tint when illu- 
minated than the rest of the ligament. When the vocal cords are ap- 
proximated a small depression — the fossa innominata (ji) — may be seen 
near the epiglottis between the ventricular bands below and the ary-epi- 
glottic folds above. 

The openings of the ventricles (v) can sometimes be distinguished as 
dark lines, between the ventricular bands and vocal cords. They are best 
seen in the healthy larynx of a thin subject — especially when there is a 
slight disposition to spasm. 

The voccd cords (vc) when visible, cannot be mistaken. They appear 
as two pearly white cords, passing from the base of the arytenoid carti- 
lages to the angle of the thyroid cartilage. On inspiration, they appear 
almost to touch each other at their anterior insertion, but to be separated 
from a quarter to half an inch posteriorly. On phonation, they become 
parallel, and appear to approximate. Each vocal cord is seen to termi- 
nate behind in the angle at the base of the arytenoid cartilage, called the 
vocal process (vp). On inspiration, this angle is directed outward, and 
the glottis has a lozenge-shape; but when the vocal cords approach one 
another, the angle is turned inward. This process divides the intercar- 
tilaginous and interligamentous portions of the glottis. 

Below the vocal cords, appears the broad yellow cricoid cartilage (cr), 
and below it, again, the rings of the trachea (t) are seen elevating the 
mucous membrane, which between them is of a pale pink color. Occa- 
sionally, two indistinct dark circles (the openings of the bronchi), on 
either side of a bright projecting line (the angle of division between the 
bronchi), indicate the bifurcation of the trachea, and in some rare cases, 
a ray of light may even be thrown down the right bronchus. 

Though external to the larynx, it is necessary to mention the si?nts 
piriformis (sp) in which foreign bodies are extremely likely to become 
lodged. It is bounded on the inner side by the ary-epiglottic folds, and 
on the outes side by the inner surface of the thyroid cartilage. 



LARYNGEAL INSTRUMENTS. 

In operating within the larynx the laryngeal mirror should be held in 
the left hand, and the instrument in the right. It is seldom necessary to 
employ an assistant to steady the head, except in the case of very young 



LARYNGEAL INSTRUMENTS. 



179 



children. Before describing the various instruments in detail, I may ob- 
serve that whilst most Continental practitioners, as a rule, use laryngeal 
instruments curved like a catheter, from the first I employed those of a 
more angular form, and this type is universally used in England, and 
pretty generally in America. In a catheter the two extremities are at 
right angles to each other; but the angle is reduced to a minimum by a 
large curve or sweep. This curve, though well adapted for the urethra, 
is much less suitable for the larynx; and if, on the other hand, the right 
angle, slightly smoothed down, is left, the instrument in passing into the 
larynx is kept free of the epiglottis. My meaning will be at once clear 




Fig. 26.— Laryngeal Probes. 

on reference to Fig. 44. It will be seen that both the catheter-curved 
instrument (indicated by dotted lines), and ray rectangular instrument 
reach the same spot; but whilst the former touches, and even presses 
against the epiglottis, the latter avoids it. Hence the superiority of the 
rectangular instrument. 

Probes. — It occasionally happens that it is desirable to introduce sounds 
within the larynx. By means of such instruments the origin and density 
of a growth may sometimes be ascertained, when with the unaided 
laryngeal mirror the information cannot be obtained. In cases of ulcera- 







Pig. 27. — Laryngeal Brushes. 



tion over the arytenoid cartilages they often enable the practitioner to 
ascertain the extent of the burrowing and the condition of the cartilages 
themselves. In cases of altered sensibility of the larynx, relative differ- 
ences may be ascertained. 

Brushes. — For applying solutions to the larynx, squirrel's or camel's- 
hair pencils, either cut square at the end or pointed, according as a large 
surface or small spot has to be touched, and firmly attached to aluminium 
wire bent at an angle of about 90°, will be found most suitable. Brushes 
of different lengths and sizes are required, according to the situation and 
nature of the case. For ordinary use, three brushes will be sufficient, and 



180 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

these are made of definite dimensions. The shortest size (Xo. 1) meas- 
ures two inches in length from the angle to the end of the brush. The 
length in the medium size (Xo. 2) from the angle is two inches and a 
half. In the longest (Xo. 3) the length is three inches. In all cases the 
metal shank of the instrument between the handle and the angle should 
measure at least an inch, and the wooden handle about seven inches. 
The handle should be octagonal, and should taper down toward the metal ; 




Fig. 28.— The Croup-Brush. 



and in hospital practice, or where a large number of cases are seen, it 
saves a good deal of trouble in sorting and selecting to have the handles 
of brushes Xos. 1, 2, and 3, colored, white, red, and black respectively. 
The Croup-Brush (Fig. 28) is made of squirrel's tail, and the hairs cover- 
ing the sides of the brush are directed upward. It is mainly useful for 




Fig. 20.— The Sponge-Holder : 
is raised in A, but closed in B.) 



A, the holder open ; B, the holder with sponges. (The safety-wedge («, 



detaching false membrane from the larynx and trachea in croup, but it 
may be employed for applying remedies in the case of children — when the 
laryngoscope cannot be used. 

Sponges were at one time much used by Dr. Fauvel, of Paris, for ap- 
plying solutions to the larynx, and they possess the advantage that a 
perfectly new sponge can be used for each, patient at every visit. I have 
lately employed a very excellent American sponge-holder in this way, 



LARYNGEAL INSTRUMENTS. 



181 



after having slightly modified the instrument in order to make it quite 
safe. To prevent the possibility of the sponge dropping, I have added a 
wedge, which fixes the blades of the sponge-holder immovably together. 
Dr. P. C. Smyly, of Dublin, uses cotton wool attached to a piece of bent 
aluminium wire by means of strong thread; the instrument is thrown 
aside after being once used, and fitted with a fresh piece of wool for each 
occasion. 

Laryngeal Injectors. — Various kinds of syringes have been invented 
for injecting fluids into the laryngeal cavity. I do not recommend this 
method of treatment, but those who wish to practise it will find Hartewelt's 




Pig. 30.— Hartewelt's Drop Injector. 

Drop Injector (Fig. 30) a very manageable instrument. It is a hollow 
tube made of vulcanite, and suitably curved for introduction into the 
larynx. At the junction of the shank and the handle, on the upper part 
of the instrument, is a small cavity covered with a drum-like piece of 
caoutchouc and communicating with the interior of the tube. The injec- 
tor is filled by pressing the air out of the cavity, and inserting the point 





Fig. 31.— Professor Siegle's Inhaler. 



of the instrument into the solution to be used. This instrument is made 
in two parts, so that the same handle can be employed with different 
tubes, and the points of the tubes are also made in different ways, some 
having a number of small holes, so that the stream is diffused; while 
some have only a hole at one side, so that the fluid passes only in one 



182 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

direction, etc., etc. The injector is held between the thumb and second 
finger, and the index finger remains free to press on the elastic drum 
when the point of the instrument has been passed into the larynx. The 
late Dr. Gibb used a small syringe with a fine curved silver extremity, 
terminating in a small, finely perforated ball, by which showers of " the 
solution were distributed through the larynx." The principal objection to 
the use of injectors is that they have a tendency to cause more spasm than 
brushes, and with them it is more difficult to limit the amount of the ap- 
plication, or to confine it to certain spots. 

Inhalers. — For the application of liquids to the larynx, in the form of 
a very fine spray, many kinds of " atomizers " have been invented; but 
Bergson's tubes have, in point of fact, superseded all others. These are 
applied in Dr. Andrew Clark's handball Spray-Producer, in which an in- 
dia-rubber ball supplies air as the motive power, and in Professor Siegle's 
apparatus (Fig. 31), in which the atomization of the fluid is effected by 
steam; both are good instruments. The ordinary handball Spray-Pro- 
ducer is so well known that it does not require to be illustrated. Dr. 
Solis Cohen's Spray-Producer, in which only a single ball is used, is an 
extremely useful instrument. There is no advantage in having a continu- 




FiG. 32.— Dr. Solis Cohen's Single-Ball Atomizer: a, glass points at right angles: b, vulcanite tube for 
preventing dispersion of spray : c, bottle containing medicated tluid ; d, india-rubber air-ball. 



ous spray for the throat, as the spray cannot be continuously inhaled. 
Indeed, it is more convenient to have the spray interrupted, as it can then 
be easily drawn in at each inspiration, and does not continue to flow dur- 
ing expiration and periods of rest. These instruments certainly produce 
a finer spray than those in which the fluid is pulverized by being pro- 
jected in a fine jet against a disk or button; but they are open to the 
serious objection, that in all cases a very strong current of air or steam 
accompanies the atomized liquid. "Where any dyspnoea exists, this is a 
yery objectionable feature. The employment of atomizers in throat af- 
fections is more particularly indicated in cases where, from circumstances, 
the patient cannot visit his medical attendant sufficiently often, and is 
thus obliged to carry out the treatment himself. I do not recommend the 
use of these atomizers for the inhalation of caustic solutions. 

For the inhalation of volatile medicaments, a supply of steam is all 
that is required, but the process can be best carried out with the aid of 
one of the numerous inhalers now in vogue. Those instruments are most 
effectual in which the patient inhales steam together with air, which is 
drawn through the hot liquid, and thus becomes thoroughly impregnated 



LARYNGEAL INSTRUMENTS. 



183 



with the acy»je principle of the medicament. In inhaling steam in which 
there is no such aerial current, the remedy acts much more feebly. The 




Fig. 33.— The Eclectic Inhaler. The inhaler consists of three parts, a, b, c. a is an open vase, and is 
essentially the containing vessel, into which the hot water and medicated solution are put. It is shown in 
A with a pint of water in it, and above the water-line is a large space for steam. 6 is a kind of lid resem- 
bling an inverted tumbler, which forms the cover of the containing vase. It is seen in its proper position 
in A, ami with the sides of the vase drawn diagrammatically in B. The bottom of the tumbler forms the 
covering of the vase, and the sides of the tumbler dip down into it, leaving an air-chamber between the two 
parts. When the vase contains the proper quantity of water, the sides of the inverted tumbler or lid dip 
down only about half an inch below the water-line. The circumference of the lid is perforated with small 
holes, as seen in x. and the circumference of what would be the rim of the tumbler is perforated in the 
same way at z. The apertures both above and below communicate with the air-chamber. When the 
patient inhales, air rushes through the various holes above at x, then through the air-chamber, again 
through the series of holes at z. and. finally, up to the mouth-piece, as shown by the course of the arrows. In 
the centre of the upper surface of the lid is a projecting nozzle, to which is attached a flexible tube, provided 
at its extremity with a double-valve earthenware mouth-piece. There is an opening in the lid, through 
which a thermometer, registering high temperatures, passes into the water, c is a stand on which the vase 
rests, and is made hollow, so as to hold a spirit lamp. 

Eclectic Inhaler (Fig. 33) is perhaps the most perfect of these instruments, 
but it is rather cumbersome. 

Martindale's Portable Inhaler is an excellent apparatus, and fulfils 




Fig. 34. — Martindale's Portable Inhaler: A shows the inhaler ready for use. with a woollen covering, 
to prevent rapid cooling ; B is the uncovered inhaler ; C is its upper portion, which takes off for cleansing 
the apparatus, and to facilitate the packing. 

most of the conditions of tjie Eclectic Inhaler, whilst it is much cheaper, 
and, being made of tin, is easily carried about without any risk of breaking. 



184 



DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



Bullock's Hospital Inhaler is cheap and serviceable. It is made of 
stoneware, and has a tin lid and spout, the mouth-piece of which is cov- 
ered with india-rubber. 

Dr. Lee's Steam-draught Inhaler l is a very useful instrument, as it 




Fio. 35. — Bullock's Hospital Inhaler : A shows the inhaler ready for use ; B is the lid with nose-piece 
for nasal inhalations. 



delivers the steam, and thus dispenses with the necessity for an inspira- 
tory effort. 

For the inhalation of burning substances, such as nitre, stramonium, 

Arsenic, etc., no apparatus is absolutely necessary, as they can all be 

employed by merely being lighted on any non-inflammable substance. A 

special apparatus, however, such as the Fuming-Inha- 

ler, is useful, particularly in employing nitre-papers. 

Steam Kettles are useful in laryngitis and diph- 
theria. The best apparatus of this kind is the Ven- 
tilating Croup-Kettle, of Messrs. Allen (Fig. 37), 
which constantly delivers a small quantity of steam 
in a state of very fine subdivision. 

Insufflators. — Powdered substances may be in- 
troduced into the larynx either by insufflation or by 
various kinds of injectors. This plan of treatment is 
of very ancient origin, having been introduced by 
Aretneus. The insufflators in use are (1) that of 
Rauchfuss (Fig. 38), in which the powder is expelled 
by pressure on an elastic ball at the end of the in- 
strument; and (2) the Tube-Insufflator (Fig. 39). In 
this instrument a piece of elastic tubing is attached 
to the proximal extremity of the vulcanite tube. With 
the free end of the tubing in his mouth, the operator 
blows the powder into the patient's larynx. This in- 
strument is preferable to that of Rauchfuss, as the 
sudden pressure of the thumb on the ball of the lat- 
ter instrument alters the direction of the point of the injector, and thus 
renders the accurate application of the remedy very difficult. 




Fig. 

inhaler, 
eonsists 



-The fuming- 
This apparatus 
of a cylindrical 
earthenware vessel — a vase 
in fact — four inches high 
and two inches in diame- 
ter. An open wire dia- 
chram occupies the upper 
part of the cylinder. 



Manufactured by Messrs. S. Maw, Son, & Thompson. 



LARYNGEAL INSTRUMENTS. 



185 



Porte- Canstiques. — For applying solid nitrate of silver to the larynx, 
the only instrument which is thoroughly safe, and at the same time easy 
to use, is the Laryngeal Cauterizer, first recommended by Lewin. It 
consists of a piece of aluminium wire, bent at the same angle, and of the 
same length above and below the angle as the laryngeal brush. The wire 
is roughened at its extremity and then dipped into some nitrate of silver 
fused over the spirit lamp. In this way a certain quantity of the nitrate 
adheres firmly to the wire. An ingenious porte-caustique has been in- 




Fig. 37. — Messrs. Allen's Ventilating Croup-Kettle. 




Fig. 38.— Dr. Rauehfusb's Injector : a, a movable tubular covering ; b, the cavity into which the powder 
is put. 




Fig. 39. — The Tube-Insufflator : a, a movable tubular covering ; 6, the cavity into which the powder ts 
put ; c, stop, which closes the passage until it is pressed down : d, valve which allows the air to pass to- 
ward the laryngeal extremity of the instrument, but prevents the patient expiring or coughing through 
the tube. 



vented by Dr. Fauvel, in which, whilst the stick of nitrate of silver is 
safely enclosed, the point, by a spiral spring behind it, is always kept 
protruding. Professor Stoerk, of Vienna, also, when laryngoscopy was 
quite in its infancy, contrived a porte-caustique in which the caustic re- 
mains concealed till brought to the part desired to be touched, when, by 
pressure on a spring in the handle, it is made to protrude. My laryngeal 
lancet is provided with a small piece of aluminium wire, which can be 
fitted on in place of the cutting blade; in this way it becomes a guarded 
porte-caustique. The nitrate of silver is attached to the wire by fusion 
in the way already described. 

Besides these instruments, various others have been invented, but the 
simple aluminium wire answers the purpose perfectly well. 



186 DISEASES OF TUE PHARYNX, LARYNX, AND TRACHEA. 

Laryngeal Electrodes. — These instruments are used dafly by nearly 
all laryngoscopists. They are so constructed that the current does not 
pass till the metal point or sponge is in contact with the vocal cords. 
The instrument is held in the hand between the thumb and second finger, 
and when the sponge has been placed in the desired position, the operator 
with his index finger presses on the key in the handle, and the electric 




T— -^ 



3 9 \ J> 

Q 



Fig. 40.— The Author's Laryngeal Electrodes and Necklet : A, the laryngeal electrode : a. a metal ring 
by which the electrode is connected by a chain either with a battery or a magneto-electric machine ; o, the 
extremity of a wire communicating with a ; c, metal point, which, when the ivory handle, d, is pressed 
upon, touches b. The current then passes along the wire, e (which is insulated in caoutchouc), to the 
metal ball, /. This completes electrode No. 1. g represents the spade- shaped electrode for applying the 
current to the posterior crico-arytenoid muscles : the handle of the instrument is of wood or glass. B is the 
necklet which the patient wears ; ch is the chain by which the necklet is connected with the apparatus 
producing the electricity. 



current passes through the larynx to the skin externally. At the same 
time the patient wears a necklet communicating with the other wire of 
the battery. 

In Dr. Fauvel's modification of my instrument (Fig. 41, A), the two 
poles are united in the same handle. The two rods are carefully isolated, 
and only when the little key on the upper part of the instrument is 
touched does the current pass between the two brass knobs. In a third 
instrument here shown (Fig. 41, B), the electrodes are more widely sepa- 
rated, so that they can straddle across the ary-epiglottic fold, and embrace 




Fig. 41.— Laryngeal Electrodes Nos. 2 and 3 : A represents Dr. Fauvel's modification of my instrument,, 
which is called No. 2 electrode. The current passes between the two knobs at c. B represents the adductor, 
or Xo. 3 electrode. It is introduced into the Larynx in such a way that the pole, o, is in contact with the 
vocal cord, and u passes into the hyoid fossa. In this way the lateral crico-arytenoid is embraced be- 
tween the two poles. The extremity of the hyoid electrode should be about five-eighths of an inch distant 
from, and slightly posterior to. the pole which is applied to the vocal cord. 



the lateral crico-arytenoid muscle. This arrangement is useful for limiting 
the electric current to the thyro-arytenoideus muscle. 

Laryngeal lancets are of various kinds. My own instrument consists 
of a small double-edged knife or lancet, which is contained in a hollow 
tube, suitably curved for introduction into the larynx. The point of the 
lancet is concealed in the duck-billed extremity of the tube till forced 



LARYNGEAL INSTRUMENTS. 



187 



out by pressure on a spring in the handle. The stock of the instrument 
is provided with tubes bent at different angles, and below the angle is a 
joint which enables the operator to lengthen or shorten the tube. This 
arrangement allows for the varying inclination which the plane of the 
laryngeal aperture bears to the horizon, and renders the lancet fit for 
operating either at the upper or lower part of the larynx. The length of 
the blade is regulated by a screw in the handle. The instrument is held 
between the thumb and second linger, and when its extremity is brought 
opposite the part which the operator wishes to lance, he presses on the 




Fig. 4"2.— The Guarded Laryngeal Lancet and various Knives : Sp, the spring which forces out the lan- 
cet : when it is pressed down to the dotted line, the lancet, I, protrudes : h, the handle ; Sc, the screws, by turn- 
ing which the length of the point of the lancet can be regulated : t, junction of the barrel and stock of the 
instrument. At this point, barrels curved at different angles can be applied. 6, the bayonet joint. A 
shorter or longer tube can be put on here, according to circumstances, and the blade can be taken out and 
cleaned. The engraving also shows the various blades recommended by Tobold. 




Fig. 43.— The Authors Cutting-Forceps : A, the lateral forceps ; B, the anteroposterior forceps; C, 
spoon-shaped forceps ; D. punch-forceps. 



spring in the handle with his index finger. Dr. Tobold's unguarded 
knives give more power to the operator than can be obtained with the 
movable concealed blades of my protected Laryngeal Lancet, but their 
use should be confined to the hands of those thoroughly skilled in the use 
of laryngoscopic instruments. 

The common laryngeal forceps are made of different lengths and 
curved at different angles. Some open like ordinary forceps, laterally 
(Fig. 43, A), whilst others open backward and forward (Fig. 43, B). The 
instrument is shown in situ in Fio-. 44. I now scarcely ever use any 



188 



DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



other instrument than these forceps for removing laryngeal growths. 
Larger experience has also convinced me that forceps should not be slen- 
der, but, on the other hand, rather stout. There is too much vibration 
and too little firmness in the slender instruments, and though they look 
much more suitable for delicate operations, carried out with the laryngeal 
mirror, they are in point of fact less serviceable. Dr. Fauvel, who has 
been so remarkably successful in the removal of growths from the larynx, 




Fig. 44.— The Author's Common Lateral Forceps, shown in situ. 

uses even stronger and larger forceps than myself. In order to grasp 
the growth more firmly he also has a catch fixed to the rings of the han- 
dles, so that, when desired, the blades can be made to lock. 

Hie tube forceps consist of a steel tube of a diameter of one-tenth 
of an inch, containing the forceps. It is bent at an angle of 90°, but to 
the same stock barrels of different angles can be applied. Just below 
the angle is a joint which enables the practitioner to clean the forceps 
and apply shorter or longer blades, as the case may require. The spring 
which forces the tube over the forceps is at the anterior and upper part 
of the handle ; and the operator, holding the instrument between his 



LARYNGEAL INSTRUMENTS. 



189 



thumb and second finger, presses on the spring with his index finger. 
At the posterior part of the handle is a ring, by which the forceps can 
be made to revolve, and in this way the blades can be made to open 
backward and forward, or from side to side. This arrangement enables 
the operator to seize excrescences, whether they grow from near the 
anterior insertion of the vocal cords, from the arytenoid cartilages, or 
from either side of the larynx. The blades of the forceps have sharp- 
cutting teeth all round their edges. For most cases, the blades which 
pass down perpendicularly from within the tube containing them are 
convenient ; but sometimes where the growths are thin and membranous, 
and have an extensive origin from the side of the larynx, forceps, with 




Fig. 45.— Dr. Fauvel's Forceps : A, the handle of the instrument, showing the arrangement for locking 
the blade ; B, the lateral blades ; C, the antero-posterior blades, showing the manner in which one blade 
plays in a slot. 

blades opening horizontally, will be found more suitable. In this case 
the forceps have in fact only one movable blade, which is at right angles 
to the shank, the other blade being let into the tube : the two blades of 
the forceps close when the tube containing the upper blade is forced 
down by the pressure of the index finger on the spring in the handle. 

At the joint below the angle of the instrument scissors can be fitted 
instead of the forceps. In order that the blades should readily cut, the 
shanks of the scissors should cross one another above the blades ; the 
scissors have hooks on each blade, which seize the divided particles and 
prevent their falling into the trachea. 



190 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

Schroetter's laryngeal forceps are of the tube character, but the 
handle is placed at an oblique angle to the shank, so that the operator's 
hand is kept to one side, altogether out of the field of vision. The 
upper blade is fixed, being in fact part of the tube, whilst the lower 






Fig. 46.— The Author's Tube-Forceps and Scissors: Sp, the spring, by pressing on which the tube is 
forced over the base of the forceps ; b, the joint at which longer or shorter tubes may be applied, and the 
blades taken out and cleaned. (This joint has been made unnecessarily large by the draughtsman. ) r, 
the ring, by turning which the forceps revolve so that the blades open in any direction : Sc, the screw for 
taking the instrument to pieces, cleaning it, etc. ; 1, the perpendicular blades ; 2 and 4, horizontal blades ; 
3, the scissors, with hooks attached to them. 

blade is attached at right angles to a solid wire which moves within the 
tube. In order to reach growths in different parts of the larynx, several 
tubes are required for the same handle, as the forceps have only one 
movement /'viz.. the upward movement of the lower blade), which is 




Fig. 47.— Professor Schroetter's Forceps. 



brought about by touching a slide in the handle of the instrument with 
the thumb. These forceps are only adapted for removing very small 
growths, but they are particularly convenient for effecting evulsion at 
the anterior commissure of the vocal cords. 

lScraseurs of different construction have been used for the removal 
of laryngeal growths with more or less success since the invention of 
the laryngoscope. In this country Drs. Walker, Gibb, and George 
Johnson have employed them ; whilst in France an feraseur, combined 
with a kind of dart, which is said to transfix the growth, has been 
recommended by Moura-Borouillou. 



LARYNGEAL INSTRUMENTS. 



191 



To these instruments I always entertained the objection, that the 
wire was very likely to be displaced, and that the growth could only be 
accidentally ensnared after repeated trials. This inconvenience was, 
iiowever, overcome by Professor Stoerk, who had an ecraseur constructed 
in such a way that the wire is concealed in a solid loop of metal. This 




Fig. 48.— Professor Stoerk*s Guillotine and Forceps : A, wire Ecraseur ; B, guillotine : C, ditto (larger); 
D, E, and F, forceps ; G and H, improved guillotine, avoiding the loss of space in B and C ; H shows the 
guillotine open ; G, the same instrument half closed. 



prevents the wire being pushed aside when the operator proceeds to put 
it over the growth. The instrument is thus rendered much more service- 
able, but it really acts more on the principle of a guillotine than an 
ecraseur, and, indeed, Professor Stoerk employs the same handle with a 
circular knife instead of the wire. For operating on very large growths 



192 



DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



I have, however, used a modification of Stoerk's instruments, in which, 
by means of a cog-wheel, that can be turned by the index finger, the 
wire slowly crushes through the growth on the true principle of the 




Fig. 49.— The Author's Guarded-Wheel Ecraseur. 



ecraseur. I have called this instrument the guarded-wheel ecraseur. 
Two cases in which it had been employed were brought by me before 
the Pathological Society ' some years ago. 



DILATORS OF THE LARYNX. 

For dilating the larynx when it has become blocked up by organized 
membrane or by cicatricial tissue, various dilators have been invented. 
In most cases the use of these instruments is facilitated by the previous 




Fig. 50. — The Author's Dilator : A, the instrument closed ; by turning the screw, s, the blades separate, 
whilst the dial, d, shows the extent to which the dilatation has taken place. 

performance of tracheotomy, which is almost certain to have become ne- 
cessary. 

1 Trans. Path. Soc, pp. 52 and 53 (1870). 



DILATORS OF THE LARYNX. 



193 



TJie screw dilator is an instrument which I have occasionally used for 
the last fourteen years. It consists of three blades which, when united 
together, form a solid instrument easily introduced into the larynx. 
When the instrument has been passed into the constricted larynx, a screw 
at its proximal extremity enables the operator to open the blades and 
thus effect distention, the degree of which is shown on a dial placed near 
the screw. 

Professor Navratil, of Pesth, has invented an instrument very much 
on the principle of my dilator, but much more perfect in its details, and 
consisting of four segments instead of three; moreover the dilating action 
in his instrument is confined to its laryngeal portion, whilst in mine it ex- 
tends a little above its angle. The only objection to Professor Navratil's 
instrument is its extremely complicated construction, which renders it lia- 
ble to get out of order and difficult to clean. 

Dilating tubes were first introduced by Professor Schroetter, and the 
profession is greatly indebted to that physician for developing the treat- 




Fio. 51. — Professor Navratil's Dilator. This instrument consists of a silver tube containing a steel red, 
terminating at the distal extremity in an olive-shaped body, rather pointed below and broad above, the di- 
ator proper (d and f d), and at the proximal end in a screw (Sc) : between the two is a handle (ft), which 
the patient holds alter the introduction of the instrument into the mouth. The olive-shaped dilator varies 
in length from 4% to 6 centimetres, and its diameter is from 12 millimetres to 8 millimetres above, and 
from 5 millimetres to 2 millimetres below. The olivary body (d and f d) consists of four segments, each seg- 
ment having three joints ; the segments can be made to extend symmetrically to a distance of from 20 to 
30 millimetres by turning the screw, and a measure on the instrument, between the handle and its proximal 
extremity, indicates the amount of dilatation that has taken place. 



ment of a very difficult class of cases. Professor Schroetter originally 
employed hollow curved tubes of vulcanite of various sizes. Small tubes 
are first used, and subsequently when the larynx is more dilated, larger 
tubes can be employed. The fact that these tubes (although hollow and 
thus permitting the patient to breathe) cannot be tolerated for more than 
a few seconds on account of the pharyngeal irritation and retching which 
they produce, led Professor Schroetter to invent the instrument now to be 
described. 

The Laryngeal Dilating -Plug. — This instrument consists of a leaden 
plug, which is temporarily attached to a suitably curved hollow tube by 
means of twine passing through the tube. It can only be used when 
tracheotomy has been previously performed, and a canula is worn with 
an opening in its upper surface. The plug is introduced into the larynx, 
and its lower end, which is perforated bv an oblique passage, passes into 
13 



194 DISEASES OF THE PIIARYNX, LARYNX, AND TRACHEA. 

the tracheal canula. It is retained in this position by a bolt, which takes 
the place of the ordinary inner tube of the canula. "When the plug is 
thus fixed in position the laryngeal tube is withdrawn, whilst the twine 
which is left protruding from the mouth can be tied round the neck or be- 
hind one ear. When it is desired to withdraw the instrument the bolt is 




Fig. 52. — Professor Schroetter's Dilator: A, the instrument ready for use. It is a hollow, curved tube, 
fitting into a perforated handle, and terminating in a metal plug (x). The latter is kept attached to the 
tube by a piece of twine, which passes through the tubular instrument, and is fixed to the proximal ex- 
tremity of the handle by a clip. The metal plug has a ring at its upper part and a small canal {y) passing 
obliquely through its lower extremity. B is a fine silver rod, by means of which the twine is drawn 
through the tube when it is being prepared for use ; C corresponds to the inner tube of a tracheotomy ca- 
nula, which, instead of being continued as a tube, terminates in a bar (e), passes through the plug when in 
situ (i. e., in the contracted larynx) and bolts it in position. 

removed from the canula and the plug is drawn up from the larynx by 
means of the twine. It may be allowed to remain in the larynx for an 
hour or half an hour the first time, but this period may be gradually in- 
creased until the patient retains it for the whole day. 




Fig. 53.— Dr. Whistler's Cutting-Dilator: A is the olivary extremity of the instrument, with the blade 
concealed ; B shows the blade projecting from its sheath, when the key (A.) is pressed upon ; and C, the 
blade altogether removed from its covering. 



The Cutting -Dilator. — Dr. Whistler has invented a very ingenious 
cutting-dilator, which is particularly serviceable for dividing webs or 
membranous formations. 



ACUTE CATARRHAL LARYNGITIS. 195 

This instrument consists of a pointed, olive-shaped bod\ T , placed at the 
end of a suitably curved shank, and containing within its interior a sharp 
blade, which can be made to protrude by touching a little key in the up- 
per part of the handle. When the instrument is passed into the larynx, 
any existing web is put upon the stretch, and thus rendered tense for di- 
vision. The knife is so arranged that it can be made to cut forward to 
ward the anterior commissure or backward toward the inter-arytenoid fold, 
according to the situation of the stricture. 



ACUTE CATARRHAL LARYNGITIS. 

(Synonyms : Spurious Croup. Acute Catarrh of the Larynx. 

Acute Laryngitis.) 

Latin Ej. — Laryngitis acuta catarrhalis. 
Ifrench. Eq. — Laryngite catarrhale. 
German Eq. — Akuter kehlkopfkatarrh. 
Italian Eq. — Catarro acuto della laringe. 

(See also CEdematous. Laryngitis.) 

Definition. — Acute catarrhal inflammation of the mucous membrane 
of the larynx, seldom dangerous to life, giving rise to hoarseness or 
aphonia, and sometimes to slight dyspnoea and stridulous breathing in 
children, in whom, however, it almost invariably ends in resolution. In 
adults, it often passes into the chronic form of inflammation, and in very 
rare cases may result in oedema. 

History. — This disease was partially described by Millar, 1 more than 
100 years ago, but that observer gave an obscure picture of the affection 
from mixing up catarrhal laryngitis with spasm of the glottis. Hence 
he was led to regard the complaint as a neurosis, and to recommend anti- 
spasmodic remedies. Guersant 2 first gave a clear account of the pathol- 
ogy of the disease, and employed the terms "faux croup" and "laryn- 
gite striduleuse." 

Etiology. — The causes which provoke acute catarrhal inflammation of 
the larynx are such as favor analogous affections of mucous membranes 
generally, amongst which, in so-called temperate climates, "catching 
cold " is the most common. Cold draughts of air, whether inspired 
directly, or bearing on the neck and ears externally, are particularly 
liable to give rise to laryngeal catarrh. Exposure of the body in gen- 
eral to cold, and especially allowing the feet to remain wet and cold for 
any length of time, are also common causes of an attack. As Krieger 3 
well points out. children whose vital power has been lowered by pro- 
longed confinement to the house in bad weather often catch cold in their 
first walk through dusty streets on a windy day. But frequently the 
cause of laryngeal catarrh is of a more local nature. Thus violent func- 

1 Observations on Asthma and Hooping- Cough, London. 1769. 

2 Revue Medicale, Octobre, 1829. 

Cited by Rauchfuss : Loc. cit. 



196 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

tional efforts (as in giving the word of command, preaching, singing, 
etc.), as well as straining the parts in coughing, are not uncommon 
causes of it. Hot alcoholic drinks, excessive tobacco smoking, dusty 
air, irritating vapors, foreign bodies accidentally entering the larynx, 
may also be enumerated as frequent excitants of the disease. Or it mav 
be propagated from the nares and pharynx, the more severe forms o*f 
inflammation of the latter region being especially prone to spread to the 
neighboring region of the larynx. Extension of the disease occasionally 
takes place from below, the bronchial tubes being first affected ; but the 
opposite sequence is more usual, the laryngeal inflammation passing off 
with the occurrence of bronchitis. Relaxing habits and indoor occupa- 
tions undoubtedly predispose to the disease. At the Hospital for Dis- 
eases of the Throat, catarrh of the larynx is much more often met with 
among tailors, shoemakers, house-porters, and people thus engaged, than 
among coachmen, cab-drivers, policemen, and others who are constantly 
exposed to the most inclement weather. Previous attacks, especially if 
several times repeated, increase the susceptibility of the individual to a 
renewal of the affection. Males are more liable to it than females, and 
adults than children, but in young subjects the disease gives rise to 
much more marked symptoms, and hence attracts more attention. Laryn- 
geal catarrh is also a very usual accompaniment of hay asthma, and is 
often met with in the exanthemata, especially in measles. 

Symptoms. — The patient complains at first of slight dryness or sore- 
ness of the throat, with hoarseness, and a disposition to cough. This 
sensation varies from a mere feeling of tickling or roughness, to a sense 
of constriction about the throat, with slight odynphagia. It rarely hap- 
pens that manipulation of the organ from without causes pain, but great 
uneasiness is sometimes experienced on attempted phonation. The voice 
is usually at first hoarse or defective in timbre, but afterward it may be 
extinguished. The cough may be altogether absent, but it is generally 
rather shrill, and in severe cases may be aphonic. The respiration is not 
affected as a rule, but, as will be presently shown, it is sometimes embar- 
rassed in children, the narrow area of the glottis, in young subjects, easily 
resulting in some stenosis, and a corresponding difficulty of breathing. 
In the adult, on the other hand, considerable swelling may ensue, without 
curtailing the breathing space. The inspiration is, however, generally a 
little prolonged and occasionally associated with stridor, and mucous 
rales can usually be heard on auscultating the larynx. Slight mucous 
expectoration accompanies these symptoms, but if the secretion becomes 
thick, purulent, and abundant, it may be regarded as coming from the 
bronchial tubes. 

In children there is sometimes marked fever, the tongue is white and 
furred, with red tip and edges, the pulse frequent and hard, the skin 
hot, and the face flushed. In these young subjects suffocative attacks, 
occurring during sleep, are an important feature of the disease. This 
symptom has given rise to considerable confusion, both in theory and 
practice, as well as to much warm debate in medical circles. It generally 
occurs in children w T ho, without constitutional disturbance, have mani- 
fested during the daytime some degree of hoarseness and cough, but to 
such a slight extent as not to excite any apprehension. At night the 
scene is suddenly changed. The child who has been sleeping some hours 
wakes up in terror, its breathing is labored, inspiration prolonged and 
noisy, voice and cough husky, features congested, and its whole aspect 
one of impending suffocation. In the general alarm the little patient is 






ACUTE CATARRHAL LARYNGITIS. 197 

apt to be drugged and nauseated, proceedings which a knowledge of the 
actual state of things will show to be for the most part unwarranted. 
This form of the disease has been called laryngitis stridulosa, and it has 
been generally thought to be due to spasmodic action of the adductors 
of the vocal cords. It is probable that muscular action operates as a 
secondary cause, but that it depends primarily on the laryngeal secretion 
becoming inspissated during sleep, when the mouth is often open. Col- 
lecting in this state in the very narrow glottis of the child, and adher- 
ing to the vocal cords, the thickened mucus gives rise to a gradually 
increasing impediment to respiration, till the terrified little patient 
awakes in a storm of anguish. Between crying, coughing, and vomiting," 
the difficulty is got over, and the child shortly falls asleep, to repeat, it 
may be in a few hours, a scene which to the uninitiated presents all the 
features of impending death. 

The laryngoscopic appearances vary with the degree of severity of 
the attack, as well as with the stage at which the inspection is made. 
In mild cases, and at an early period, the whole of the mucous membrane 
is of a bright red color, though the hyperemia may be confined to certain 
parts, such as the posterior extremities of the vocal cords, the inter- 
arytenoid fold, or the ventricular bands. Sometimes there is distinct 
injection of the vessels, but usually the congestion is general. Occasion- 
ally hemorrhage takes place either into the tissues or from the mucous 
surface. The latter variety has been called laryngitis hemorrhagica, but 
it is scarcely necessary to give a special name to so rare and accidental a 
condition. I have met with a few cases, and examples have been recorded 
by Navratil ' and Friinkel. 2 In these, as well as in nearly all the other 
recorded cases, the congestion was slight, and the hemorrhage almost 
always resulted from some violent expiratory effort, such as coughing or 
vomiting. In more severe forms the mucous membrane is swollen, as 
well as red ; and when, as frequently happens, the ventricular bands are 
affected, the turgid state of these folds causes them to overlap the vocal 
cords, so that the latter are entirely concealed, or seen only as slender 
threads of a reddish tint. When the ary-epiglottic folds are attacked 
they generally maintain their normal shape ; ' and, in these cases, the 
epiglottis is seldom inflamed to such an extent as to block out the view 
of the larynx. Small patches of shallow ulceration, or erosions, which 
amount to little more than a desquamation of the epithelial layer of the 
mucous membrane, and leave no cicatrices on healing, are not unfre- 
quently to be seen. They constitute the erosions glandulaires of French 
authors, according to whom they arise from suppuration in the follicles 
of the larynx. The point at which the pus escapes becomes a minute 
ulcer, which heals rapidly. 3 

Various modifications of the mechanism of the larynx, to which the 
objective phenomena already described are due, may also be observed. 
Thus the changes in vocalization, noticed at the very commencement of 
the attack, may be seen, in some cases, to depend upon a protrusion of 
the swollen inter-arytenoid fold between the vocal cords ; or on a similar 
obstacle at the anterior commissure. Both these conditions are, however, 
as Ziemssen 4 remarks, comparatively rare. It is more frequent when the 



1 Laryngol. Beitrage, Leipzig-, p. 18. 

2 Berlin. Klin. Wochenschrift, 1874, No. 2. 
3 Krishaber: Diet, des Sciences Med., art. Larynx, Paris, 
4 Cyclopaedia of Med., vol. iv. 



198 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

patient attempts to vocalize to find a defect in the parallelism of the 
cords, their free margins presenting a concave outline, and forming an 
open glottis inconsistent with perfect phonation. This condition, as 
Gerhardt ' points out, is often caused by palsy or paresis of the thyro- 
arytenoid muscles, and indicating, as it does, an early change in the 
nerve supply of the intrinsic muscles, has a deep physiological import. 
Although the elementary character of this treatise prohibits the dis- 
cussion of this suggestive topic, it may be remarked that the derange- 
ment of motor function often precedes the superficial hyperemia, which 
from being a more striking feature is apt to be regarded as the earliest 
expression of the inflammatory state. The alteration of the voice thus 
early brought about points unmistakably to an interference with the 
innervation of the region as the initial step in some cases of inflamma- 
tion. But whatever hypothesis is ultimately adopted to explain the 
phenomena in question, the fact that " the longitudinal, and perhaps 
also the transverse tension of the vocal cords is incomplete, and probably 
also unequal," is regarded by Ziemssen, 2 with whose opinion I entirely 
agree, as a probable explanation of the " huskiness, jarring, and shrillness 
of the voice," which characterize the early stages of the disease. 

In very severe cases oedema may occur, and rapidly give rise to a seri- 
ous stenosis. This condition will be referred to under " cedematous laryn- 
gitis ;" but it may be here remarked that acute catarrh of the larynx 
is, in the majority of instances, a superficial and transient affection, which 
under suitable treatment generally ends favorably in the course of a few 
days. If neglected, however, it is likely to pass into chronic laryngitis, 
and is occasionally the starting-point in the formation of papillary growths 
and other neoplasms from the mucous tissue. 

Pathology. — Catarrhal inflammation of the larynx consists in a hyper- 
emia of the vessels of the mucous membrane. It may be either active 
{i. e., fluxionary) or passive. In effect it causes a reddening of the mu- 
cous membrane, together with an increased succulence of the epithelial 
layers, and a corresponding excess of secretion, consisting, for the most 
part, of a watery fluid containing imperfectly developed epithelial cells. 
The vascular turgescence increases the lateral pressure on the walls of the 
vessels, and causes changes in their intimate structure. At first only the 
plasma of the blood exudes, but soon an immigration of colorless corpus- 
cles takes place. In inflammation of moderate severity, these migratory 
cells disappear with the hyperemia, but when the inflammatory process is 
more persistent they become organized and converted into lymphoid tis- 
sue. These lymphoid degenerations will be again referred to under the 
head of " Chronic Laryngitis." Sometimes, beyond a sodden condition 
of the mucous membrane there are no pathological phenomena. If the 
patient die from other cause, on post-mortem examination the hyperemia 
is frequently not discoverable, and this is often the case when the con- 
gestion during life has assumed very considerable proportions. The prob- 
able explanation of this anomaly is to be found in the rich endowment of 
the mucous membrane of the larynx with elastic fibres, the contraction of 
which in articiUo mortis removes the engorgement of the capillaries by 
pressing out their contents. 

Diagnosis. — A due consideration of the foregoing conditions, both 
objective and subjective, should leave little room for doubt as to the na- 



J Handbuch der Kiuderkrankheiten, Tubingen, 1878, oter Baud. 2te Hfte., p. 322. 
2 Op. cit. 



ACUTE CATARRHAL LARYNGITIS. 199 

ture of the affection, except perhaps in the case of very young children. 
In catarrh the .symptoms, though they may remit, do not pass off so com- 
pletely as in laryngismus. In diphtheritic inflammation, i. e.jtrue croup, 
the symptoms are much more severe, and there is often the presence of 
false membrane in the pharynx. In the absence of the latter phenome- 
non, the absolute necessity for confirming the diagnosis by laryngoscopic 
inspection, where it can be accomplished, is evident. The possibility of 
a foreign body having- entered the air-passages must not be forgotten. 

Prognosis. — This is always most favorable. Mild cases of catarrh 
pass off in a few days almost without treatment, and those of more severe 
character usually quickly yield to suitable remedies. 

Treatment. — In the case of adults, the patient should be kept in a uni- 
formly warm atmosphere; should employ warm and soothing inhalations, 
such as the benzoin, hemlock, or hop inhalations of the Throat Hospital 
Pharmacopoeia, and should abstain altogether from using the voice, and 
from taking food or drink of an irritating character. A compress to the 
neck often arrests an impending attack, or cuts short the disease at its 
inception. Diaphoretics may be administered when there is any fever, 
and a purge is often useful at the outset. If there is any disposition to 
cough, the patient should be kept slightly under the influence of opium. 
The drinking of warm milk mixed with an equal quantity of alkaline min- 
eral water, as soda or seltzer water, is much praised by German authors. 
Though empirical in origin, like the proceeding sanctioned by Niemeyer 
of allowing the patient to eat very salt herrings, there can be no doubt 
that carbonate of soda and common salt exercise a solvent effect upon mu- 
cous accumulations, and it is doubtless from this cause that relief attends 
their administration. In those rare cases in which there is hemorrhage 
from the larynx, a strong astringent, such as tannic acid ( 3 ij. ad 3 j.) 
should be applied to the bleeding spot. In a case of this kind Dr. 
Smyly, of Dublin, on one occasion immediately arrested the hemorrhage 
by the application of Ruspini's styptic. When the disease begins to pass 
off, astringent solutions, such as the zinc and iron " pigments " of the 
Throat Hospital Pharmacopoeia, are often very serviceable. 

I)i the case of children, a moist atmosphere maintained by the gene- 
ration of steam is always advantageous. By this means the drying of the 
secretion during sleep is averted, and the alarming attacks of dyspnoea, 
due to this cause, are warded off. As in the case of adults, a warm com- 
press to the throat often acts very favorably, and a hot sponge over the 
sternum is a time-honored remedy in these cases. As young children can 
seldom use any apparatus which requires any effort in inspiration, the 
warm soothing inhalations already mentioned should be employed by 
means of the croup-tent (see page 122) and the " ventilating croup- 
kettle," or with the aid of some similar arrangements. Opiates are some- 
times required, and their tendency " to dry up the mucus " is best obvia- 
ted by administering the remedy in the form of the compound tincture of 
camphor, and by combining it with squills. At the same time non-depres- 
sant emetics, such as sulphate of zinc (grs. xv. to grs. xx.), or sulphate of 
copper (grs. v. to grs. vii.), in plenty of warm water, may occasionally be 
required. In catarrhal inflammation of the larynx I do not recommend 
the application of remedies with the brush, but Gibb, 1 acting on the sug- 
gestion of Horace Green, employed solutions of nitrate of silver (grs. xl. 
a( l 3 J-)j an d stated that, according to his experience, one or at most two 



Diseases of the Throat, 2d edition, p. 197. 



200 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



applications of this salt usually suffice to subdue the local inflammation. 
This treatment has been recommended by other English practitioners, 
and lately also by Professor Stoerk. 1 In my own practice, however, the 
results following the topical application of this salt have not been satis- 
factory, and I have seen the whole train of symptoms greatly aggravated 
by its use. Stoerk 2 further recommends that catarrhal laryngitis should 
be treated by the internal and external use of ice. Leeching, bleeding, 
blisters, mercury and antimony, the sheet-anchors of our j:>redecessors, are 
remedies quite out of date in the treatment of the disease, and cannot be 
put in the balance against our modern methods. 

Prophylaxis — In the case of children who possess a specially vulnera- 
ble mucous membrane, such as may be inherited from phthisical parents, 
certain precautionary measures should be adopted to diminish the suscep- 
tibility to catarrh. The best of these, perhaps, consists of tepid spong- 
ing with salt water on rising in the morning, followed by friction to the 
entire body. Judicious clothing, especially the wearing of flannel next 
the skin, should be enforced, and the adoption of regular out-door exer- 
cise insisted on. Great care should be taken to avoid over-heated sitting- 
rooms or bedrooms. At suitable seasons a residence at the seaside, for 
the purpose of sea-bathing, will generally prove beneficial. In the case 
of children and old people, the mineral waters of Royat, taken in July 
and August, greatly diminish the catarrhal tendency in the succeeding 
winters ; whilst for adults, the waters of Mont Dore have a similarly fav- 
orable influence. 



(EDEMATOUS LARYNGITIS. 
(Synonyms : Laryngitis Phlegmonosa. Laryngitis Submucosa Pu- 

RULENTA.) 

Latin Eq. — CEdema acuta laryngis vel glottidis. Laryngitis phlegmo- 
nosa. 

French Eq. — Laryngite oedemateuse. CEdeme aigu de la glotte. 

German Eq. — Phlegmonose Kehlkopfentziindung. Oedem der Glottis. 
Glottisodem. 

Italian Eq. — Laringitide edematosa. Edema acuto della laringe. 

Definition. — Acute infiltration of the areolar tissue of the larynx by a 
serous, sero-purulent, or purulent fluid, characterized in severe cases by or- 
thopncea, stridulous breathing and dysphonia or aphonia. 

History. — The descriptions of ancient authors, founded as they are en- 
tirely on the symptoms observed during life, and expressed in terms usu- 
ally vague and often confused, do not point to this disease with any de- 
gree of certainty. The observations of Hippocrates, 3 Aretreus, 4 and Cel- 
sus, 5 are equally applicable to laryngeal diphtheria, whilst those of Ciclius 
Aurelianus 6 and ^Etius 7 specially point to the plastic form of inflamma- 
tion. In 1765 Morgagni B first gave a correct account of the conditions 

1 Klinik der Krankheiten des Kehlkopfes, Stuttgart, Enke, 1876. - Ibid. 

3 Prasdict., 1. iii. 4 L. 1. cap. vi. 

5 L. iv. cap. iv. 6 L. iii. cap. ii. 

1 Bi/3Ato 'IaTp/zca, 1. v. c. 21. * De Sed. et Caus. Morb. 



(EDEMATOUS LARYNGITIS. 201 

founded on post-mortem examination, and subsequently Boerhaave ' and 
Van Svvieten * accurately described the cedematous character of the inflam- 
mation. These latter physicians did not, however, distinguish clearly be- 
tween pharyngitis and laryngitis. Gradually medical writers became quite 
familiar with the malady, and in 1801 Bichat 3 described it with consider- 
able detail, although since he speaks of it as " a particular kind of serous 
swelling which does not occur in any other situation," it is evident that 
he did not understand its pathological relations. In 1815 the various phe- 
nomena of oedema of the larynx were first scientifically portrayed by 
Bayle, 4 and from his writings we may date the commencement of the lite- 
rature of the subject. Previous to 1852 numerous papers of more or less 
importance had appeared in medical journals, especially in France, but it 
was reserved for Sestier 5 in that year to collect these and found upon 
them a standard treatise containing a vast amount of statistical evidence. 

Etiology. — The origin of the disease has been so minutely investigated 
by Sestier that it is impossible to do justice to the subject without largely 
making use of his laborious researches, which have reference to no less 
than 245 cases, 6 exclusive of cases of scald-throat. It must not be for- 
gotten, however, that certain fallacies are present in his statistics, which 
cannot therefore be taken as an unerring guide in considering the etiology 
of this disease. For the chronic and acute forms of oedema are not sepa- 
rated, and many cases where a deposit of a dense character was present 
are included as oedema. His statistics, however, must always have consid- 
erable value. 

The influence of age and sex is marked. The affection is rare before 
eighteen years of age, but prevails from that time to fifty, its maximum 
being between eighteen and thirty-five. In 215 cases, Sestier' found five 
children under five years — one a new-born infant — and twelve cases be- 
tween five and fifteen years. As regards sex, the same author noted, in 
187 adults, 131 men and 56 women. 

Acute cedematous laryngitis may be either primary or secondary, that 
is to say, it may either attack healthy persons, or may affect those pre- 
viously suffering from some other complaint. In 190 cases Sestier found 
36 primary and 122 secondary. The affection is called typical where it 
originates in the larynx, contiguous where it spreads from the pharynx or 
other parts, and consecutive where it occurs as a sequel to disease of the 
cartilages, or other structures of the larynx. 

Typical cedematous laryngitis is extremely rare. The statistics of Ses- 
tier demonstrate, and it has already been shown in the last article, that 
catarrhal laryngitis is usually a mild affection of the mucous membrane, in 
which the submucous areolar tissue is very little concerned. According 
to Sestier simple inflammation was the cause of oedema in rather more 
than 6 per cent, of all his cases. I believe that in nearly all these instances 
of so-called " simple inflammation " the disease is due to blood-poisoning. 
I have met with the affection amongst hospital physicians, piedical stu- 
dents, and nurses, and in cases where defective drainage seemed to be 
its cause. I may add that in every case that has come under my notice, 
ample opportunity of acquiring septicaemia has been present. Sestier's 

1 Aphorismi de Cognoscendis. etc., 801, 802. - Comment, in Boerhaave. 

3 Anat. descript., t. ii., p. 399. 4 Diet, des Sc. Med., t. xviii. p. 505. 

5 Trait' : de Tangine laryngee celemateuse, Paris, 1852. 

6 In some of these cases the iiltimate issue was not stated, and in others, the age 
or sex was not given. This explains how it is that the number of cases used in the 
text for statistical purposes in relation to these matters, varies in different instances. 



202 DISEASES OF THE PHARYNX, LARYNX, AXD TRACHEA. 

statistics in relation to this form of oedema bring out prominently anotln r 
fact, viz., that acute oedematous inflammation is a very rare malady amongst 
children. Thus out of the 245 cases only twice did the disease occur, as a 
primary affection, in a child. In the fifteen examples of simple oedematous 
inflammation occurring amongst adults, fourteen were men and only one 
a woman. 

Contiguous oedematous laryngitis, though rare in itself, is the most 
common form of the disease. Propagation most frequently takes place 
from the pharynx, and was found in more than 20 per cent, of Sestier's 
cases. Out of fifty-six instances where the disease originated in simple 
inflammation of the pharynx, it occurred thirty-one times in persons pre- 
viously healthy, and twenty-five times in patients convalescent or suffer- 
ing from some other affection. In Sestier's statistics there was not a sin- 
gle child among the patients previously healthy, but there were two chil- 
dren, between the ages of four and six years, amongst those already suffer- 
ing from other diseases. The greatest number of cases occurred between 
twenty and fifty years of age, and the affection was twice as frequent 
amongst men as women. The pharyngeal inflammation was in manv cases 
moderate and even slight, but the oedema of the larynx generally super- 
vened during: the height of the faucial inflammation. 1 It is highly proba- 
ble that many cases of contiguous oedema are of an erysipelatous nature, 
though it is often difficult to determine whether the disease is a true phleg- 
masia or an example of collateral oedema. As a sequel to diphtheritic in- 
flammation of the fauces, acute oedema was only noticed by Sestier three 
times in his 245 cases. Contiguous cedema rarely commences in the trachea 
and ascends to the larynx, Sestier" having only been able to find two very 
doubtful cases. Sometimes it follows aneurisms of the aorta or vessels of 
the neck, and in these cases it appears to be due to chronic inflammation 
of the cervical tissues, not to obstructed circulation. 

Consecutivi oedematous laryngitis almost always results from disease 
of the cartilages or perichondrium, but it may follow any deep-seated or 
extensive ulceration. 

Acute oedema not unfrequently occurs as a secondary phenomenon. 
The acute diseases in which it is most apt to occur are small-pox and ty- 
phoid fever, but it is occasionally met with in scarlet fever, and Boeckel 3 
has published a case supervening on ecthyma. It may occur during the 
progress of chronic tubercular or syphilitic inflammation of the larynx, 
though chronic cedema is a much more frequent sequel of these conditions. 
It is also occasionally found in post-scarlatinal dropsy, and sometimes in 
Bright's disease. Dr. Fauvel * has, indeed, pointed out that acute cedema 
of the larynx 'may be the first symptom of renal disease. This form of 
secondary oedema has also been noted by Gibbs 5 and others. 6 It must, how- 
ever, be very rare in Bright's disease, as some years ago at the London 
Hospital I examined 200 cases of this complaint without finding oedema 
of the larynx in a single instance. In the same way it is seldom present 
in general anasarca, and from the rarity of its appearance in this condition 
— a condition in itself so common — Sestier 7 thinks that the "intervention 
of phlegmasia of the pharynx and larynx or neighboring tissues is nearly 
always necessary.'' The same argument applies to Bright's disease. 

1 Op. cit. pp. 70 and 71. - Ibid. p. 09. 

Annates dea Maladies <le TOreille et du Larynx, vol. i. p. 387. 
4 Aphonie Albuminunque, Rouen, 1808. 5 Op. cit. 

6 See Specimen No. 179,050 in Guy's Hosp. Mus.; also Lancet, 1863, vol. ii p. 277, 
and 1804, Feb. 27. : Op. cit. p. 123. 



(EDEMATOUS LARYNGITIS. 203 

Symptoms, — The prominent symptom of (Edematous laryngitis is the 
gradually increasing impediment to respiration. The patient at first ex- 
periences the sensation of a foreign body in the throat, and, after a short 
time, a difficulty of breathing, which ultimately threatens suffocation. At 
the same time deglutition is rendered more or less difficult according to 
the amount of swelling of the epiglottis, and the voice gradually becomes 
weakened and altered in timbre, until at last it is almost extinct. There 
is not, generally speaking, any cough or expectoration, properly so-called, 
but the patient usually makes violent efforts to clear his throat of the ob- 
struction, and frequently succeeds in spitting up a little frothy mucus. 
To the observer, the symptoms of the malady, when fully established, are 
most striking and painful. The efforts of the sufferer to draw breath are 
from the first very evident; and, as the disease advances, the phenomena 
of orthopncea are highly distressing. Inspiration is accompanied by a 
whistling sound, which is very characteristic of the narrow condition of 
the glottis. The dyspnoea is, to a greater or less extent, constant, but 
paroxysms occur from time to time, any one of which may prove fatal. 
In these attacks the patient sits up in bed, with his mouth open, and 
gasps for breath. His eyes start from his head, and his whole body often 
trembles with an intense convulsive movement. A general cyanosis after 
a time commences, the face becomes of bluish hue, and, if nature or art 
does not afford immediate relief, death rapidly occurs from asphyxia. 

Physical examination of the part may be made by the finger or by the 
.laryngoscope, but the latter alone gives reliable information. If the fin- 
ger is passed into the throat great gentleness must be exercised, as other- 
wise we may produce a dangerous suffocative paroxysm. 1 The epiglottis 
may be felt to be very much thickened, and the ary-epiglottic folds may 
have attained such a state of tumefaction as to convey to the finger an 
impression similar to that which is given by touching the tonsils. 2 When 
the laryngoscope can be used the aspect of the parts is very characteris- 
tic. The color of the mucous membrane is generally bright red. The 
epiglottis has the appearance of a semi-transparent roll-like body or 
ridge, or, losing its normal contour altogether, it presents two round red 
swellings pressed against each other. It is often merely erect and tense. 
It is this condition of the epiglottis which explains the pain and difficulty 
accompanying the act of swallowing. In many cases the swollen epiglot- 
tis blocks the view of the interior of the larynx. Occasionally, however, 
the ary-epiglottic folds appear distinctly as two translucent folds, which 
almost meet over the entrance to the larynx, and often touch each other 
in the median line at each effort of inspiration. It rarely happens that 
the vocal cords themselves are infiltrated, but a case of this kind has been 
reported by Risch, 3 and I have twice met with a similar condition in ter- 
tiary syphilis. 

Sometimes the oedema is limited to that part of the larynx which is 
below the level of the vocal cords. This form of oedema was first accu- 
rately described by Gibb, 4 under the name of " subglottic " (edema, though 
Sestier 5 and Cruveilhier had previously made some allusions to such a 
r-ondition. In these cases there is p-enerallv no swelling; above the vocal 
cords. I have met with many examples of subglottic oedema, but they 
have all been of a chronic character. 



1 Trousseau : Clinique Medicale, t. iii. art. (Edeme de la Glotte. 

2 Krishaber : Diet, des Sc. Med., vol. ii. p. 618. 

3 Berliner Klin. Wochensch., 1866, Xo. od. 4 Op. cit. p. 211. 

B Op. cit. 6 Anat. Patholog. , t. i. 1. ii. pi. ii. fig. 1. 



204 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

Pathology. — On close inspection of the (edematous larynx in the dead 
subject, the physical appearances of the part as viewed during life with 
the laryngoscope are confirmed, whilst the pathology of the condition can 
be accurately determined. Where death has resulted from the oedema, 
the fluid collected in the submucous connective tissue is generally of a 
serous character, but it may be sero-purulent, or even healthy pus. In 
the latter case the pus is always diffused, circumscribed abscess never 
occurring as a sequel of acute inflammation of the larynx. Pure serum 
is found only in the most acute and rapidly fatal cases; as a rule the 
effusion is of a sero-purulent character. Occasionally blood is found in 
the tissues, especially in those cases which have run a rapid course. 1 On 
cutting into the diseased parts, usually but little exudation takes place, 
and sometimes even squeezing between the fingers does not suffice to 
cause the disgorgement of the ©edematous structures. As the morbid 
process so often extends from the pharynx, the brunt of the inflammation 
often falls on the epiglottis, and this valve is occasionally found enor- 
mously tumefied. But as the effusion collects where the areolar tissue is 
most lax, the ary-epiglottic folds are the parts which are most frequently 
distended, and in which the swelling attains its maximum. Next in fre- 
quency the ventricular bands suffer, whilst the vocal cords may be slightly 
tumefied, but are rarely swollen to any extent. In very rare cases the 
oedema can be traced down the trachea to the commencement of the 
bronchi. The muscles are frequently saturated with serous fluid. If the 
patient survive the acute stage and die from other causes, the parts pre- 
viously oedematous present a sodden and shrunken appearance. In con- 
tiguous oedematous laryngitis the neighboring structures are more or less 
implicated in the morbid process, and the cellular tissue of the pharynx, 
tonsils, soft palate, uvula, and even of the neck, is often found distended 
with fluid. 

Diagnosis. — Previous to the invention of the laryngoscope, oedema of 
the larynx was liable to be confounded with several other maladies, and 
where some obstacle prevents the use of the instrument, the diagnosis 
may still occasionally be doubtful. It is, however, only necessary to 
enumerate such conditions — laryngismus stridulus, polypus, retropharyn- 
geal abscess, and foreign bodies in the larynx — in order to prevent the 
careful practitioner from falling into error. Laryngeal diphtheria may 
sometimes mislead the observer, but the presence of false membrane, 
which can generally be seen in the pharynx or may be coughed up in 
shreds, determines the diagnosis. Any disease which gives rise to dysp- 
noea, such as aneurism of the aorta, narrowing of the trachea, cervical 
tumors, etc., may simulate oedema of the larynx, but the history of the 
case and the laryngoscopic examination will generally furnish conclusive 
evidence as to the real nature of the malady. 

Prognosis. — Except in slight cases, or where the oedema is partial — 
affecting one ary-epiglottic fold or one side of the epiglottis only — the 
prognosis is extremely unfavorable. Even when local measures have re- 
moved the obstruction to free respiration, the patient is very likely to 
perish subsequently from exhaustion, or blood-poisoning, or from pneu- 
monia or other lung complications. Dealing roughly with the literature 
of the subject, Sestier* found that the affection proved fatal in 158 out 



1 Sestier : Loc. cit. ; also Pf euf er : Henle u. Pf euf er's Zeitschrif t f iir rat. Med. , 
Neue Folge, Bd. iii. 

- Op. cit. p. 241 etseq. 



(EDEMATOUS LARYNGITIS. 205 

of 213 cases in spite of tracheotomy having been performed thirty times. 
In the fifty-eight cases which recovered, the trachea was opened twenty 
times. Bayle, 1 however, gives much less favorable figures, for he reports 
seventeen cases with sixteen deaths. Secondary oedema is more fatal 
than primary. The prognosis also depends on the kind of oedema as well 
as on the age and sex of the patient. Typical oedema is almost always 
fatal, whilst the contiguous form generally does well, if the inflammation 
starts from the pharynx. It is, however, invariably fatal when it spreads 
from the neck or chest, as in the case of aneurism of the aorta or of the 
laro-e cervical vessels, and nearly always so when it commences in the ex- 
ternal areolar tissue. In consecutive oedema, the local affection being 
almost always at the same time a secondary phenomenon, the prognosis 
depends on the nature of the original disease. In typhoid fever it is 
very unfavorable, whilst in phthisis the condition is in itself compara- 
tively unimportant, and in syphilis it usually yields to treatment. The 
affection is more serious in men than in women. According to Sestier, in 
the former four-fifths of the cases prove fatal, and in the latter only three- 
fifths. The same author states that the greatest mortality (in proportion 
to those affected) occurs between ten and thirty years, when eight-ninths 
of the cases prove fatal. The next highest mortality is between fifty and 
seventy, whilst the maximum power of resistance appears to be between 
thirty and forty and forty and fifty, in which two decennia, about one- 
half of the cases, according to Sestier, prove fatal. 

Treat)nent. — Prompt local treatment must be adopted in order to re- 
move the laryngeal obstruction. Local bleeding, by means of leeches 
placed over the sides of the larynx, is often of considerable service, and in 
mild cases may effect so much reduction in the oedema as to render the 
subsequent progress of the case free from danger. The inhalation of 
pulverized liquids, especially of a solution of tannin as recommended by 
Trousseau, 2 may also be tried. Ice should be uninterruptedly swallowed, 
and the patient should be kept constantly under the influence of bromide 
of potassium. It will usually, however, be necessary to carry out some 
more decisive measures. Scarification, first practised by Lisfranc, 3 is 
often successful when the disease is circumscribed. This, operation may 
be performed by means of a long, sharp-pointed bistoury, covered, except 
for the last quarter inch of its length, with adhesive plaster or lint. The 
best instrument, however, for the purpose, is the laryngeal lancet (page 
18G). A primitive method of scarifying the larynx was practised by 
Legroux, 4 who lacerated the mucous membrane with one of the finger 
nails specially sharpened to a point for the purpose. After scarification, 
gargling with warm water and steam inhalations will much facilitate the 
expulsion of fluid from the tissues. If scarification is unavailing we must 
have recourse to tracheotomy, and it is better to perform this operation 
early, than to wait until an almost moribund condition of the patient 
renders surgical interference nearly hopeless. 

Traumatic Laryngitis. 

Violent inflammation of the larynx, involving the submucous areolar 
tissue, may arise from scalds of the larynx, from corrosive poisons, or 
from the impaction of foreign bodies. 

1 Op. cit. 2 Loc. cit. 

3 Journal de Med., 1823 : Mem. sur TAngine lar. oedemat. 

4 Journ. des Connaiss. Medico-Chir., Sept., lbo9. 



206 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

Scalds oftJie larynx are frequently met with amongst children of the 
laboring classes. This accident, which is seldom seen except where Eng- 
lish customs prevail, was first described by Dr. Marshall Hall, 1 and sub- 
sequently by Stanley, 2 Burgess, 3 Wallace, 4 Ryland, 5 and Liston. 6 At a 
later period Jameson 7 reported several cases, and more recently Bevan, 8 
Ross," Jonathan Hutchinson, 10 Parker, 11 and others have recorded instances 
of the accident. These scalds are indeed far too common at all the gen- 
eral hospitals, and when I was Resident Medical Officer at the London 
Hospital, many cases came under my notice. Children allowed to drink 
tea from the spout of the tea-pot, unaware of the danger, occasionally at- 
tempt the same feat with the boiling kettle. Instant Inflammation of the 
pharynx and orifice of the larynx sets in, and in two or three hours, or 
even sooner, the epiglottis becomes greatly swollen and cedematous. 

The age of the patient usually renders'the use of the laryngeal mirror 
out of the question, but the fauces should be illuminated as in laryngos- 
copy. Under these circumstances the erect and cedematous epiglottis can 
often be seen at the back of the tongue. Scarification is the most- 
rational method of treatment. If the proper laryngeal lancet be not at 
hand, the cedematous parts may be incised or punctured with a gum lan- 
cet, or a curved, sharp-pointed bistoury, protected by strips of plaster to 
within two or three lines of its extremity. Non-depressant emetics may 
be given either before or after sacrification, the pressure which the act of 
retching exercises on the cedematous tissue favoring the effusion from the 
ruptured, or punctured, mucous membrane. Scarification, fairly and fully 
carried out, ought to supersede all other treatment, and is much to be 
preferred to leeches and mercurials. 

Tracheotomy may be had recourse to as a last resort, though it cannot 
in these cases lay claim to the success which attends its timely perform- 
ance in many other cases of laryngeal obstruction. 

Laryngitis from corrosive poisoning is generally of a very violent 
character, and is frequently followed by gangrene. Tracheotomy is often 
called for. 

Laryngitis from the presence of a foreign body can only be relieved 
by the extraction of the offending substance. The sudden swelling which 
takes place in some of these cases partakes of the character of venous 
obstruction, such as may be artificially produced by tying a piece of string 
tightly round the end of the finger. The rapidity — often only a few min- 
utes, or even seconds — with which the tumefaction takes place, far ex- 
ceeds anything that can be accounted for by inflammatory action. Should 
it not be possible to effect the removal of the foreign body, tracheotomy 
must be performed if the symptoms are at all urgent. 



I Trans. Med-Chir. Soc, London, 1822. 2 Ibid. 

* Dublin Hosp. Reports, vol. iii. " Lancet, March. 1836. 

b Op. cit. 6 Lancet, 1839 and 1840, p. 103. 

17 Dublin Quarterly Journ., Feb. , 1848. & Ibid. Feb. , 1860. 

9 Medical Press and Circ, 1868. 10 Lancet, Feb., 1871. 

II Ibid. May 1, 1875. 



ABSCESS OF THE LARYNX. 207 



ABSCESS OF THE LARYNX. 

(Under this head abscess of the larynx dependent on perichondritis is not consid- 
ered. ) 

JLatin JSq. — Abscessus laryngis. 
French Eq. — Abces du larynx. 
German Eq. — Abscess des Kehlkopfes. 
Italian Eq. — Ascesso della laringe. 

Definition. — A circumscribed collection of pus due to inflammation of 
the soft tissues of the larynx, interfering with the vocal functions of that 
organ, and sometimes with the proper action of the epiglottis. 

Etiology. — The causes of the disease are the same as those which give 
rise to diffused inflammation of the larynx. The affection is extremely 
rare, and generally occurs in an acute form. 

Symptoms. — Dysphoniaor aphonia, dysphagia, and occasionally dysp- 
noea are the ordinary symptoms. Which function is most involved de- 
pends on the exact seat of the affection. Tobold ' has reported one case 
in which the left ary-epiglottic fold w T as the seat of the disease, and 
another in which the cushion of the epiglottis was affected. Generally 
the abscess develops within the larynx, or in the lower part of the pharyn- 
geal cavity, but occasionally, as in a case reported by Ruble, 2 it points 
externally. If the abscess is not opened, it is extremely likely to cause 
suffocation, but in some cases it bursts spontaneously, and a cure results. 3 
I have myself met with thirteen cases of idiopathic abscess of the larynx. 
In six cases, the abscess occurred at the root of the epiglottis; in four, in 
one of the ventricular bands; and in three instances, one of the ary-epi- 
glottic folds w T as the seat of the disease. In most of my cases the symp- 
toms were very severe: in nine the abscess was opened with a laryngeal 
lancet, and in four the abscess burst. x\ll the patients recovered. 

Diagnosis. — It is very difficult to diagnose this affection with cer- 
tainty, for as there is generally a considerable amount of inflammation 
around the abscess the appearance is that of an acute inflammatory swell- 
ing. Sometimes, however, the abscess actually points, and the yellow 
color of the pus can be detected through the mucous membrane. As 
Professor Bruns 4 has pointed out, this yellow color is the only certain 
laryngoscopic sign of abscess, but sometimes the disease may be differen- 
tiated from oedema by the swelling being less transparent in the former 
case. 

Prog)tosis. — The prognosis is generally favorable, if the abscess has 
not attained a very large size when it first comes under treatment. In 
pre-laryngoscopic times the disease has been reported to have been quickly 
fatal in several cases. Doring b recorded a case in which a soldier died 
on the third day from an abscess at the base of the epiglottis. 



1 Laryngoscopie, Berlin, 1874, p. 324. 

; Kehlkopfkrankheiten, Berlin, 1861, p. 162 et seq. 

3 Schroetter : Klinik fur Laryngoskopie, Jahresbericht. Wien, 1870, p. 15. 

4 Laryngoscopie, Tubingen, 1873, p. 132. 

5 Ruhle : Op. cit. 



208 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

Treatment. — If the abscess is small it should be immediately opened 
with a laryngeal lancet, and if it has spread toward the skin, the opening 
should be made externally. In the case treated by Riihle, already referred 
to, a fluctuating tumor was felt with the finger, at the upper aperture of. 
the larynx, and there was a swelling over the left ala of the thyroid carti- 
lage. After using an exploratory needle an incision was made externally, 
and a cupful of pus was evacuated. The patient was cured in a few days. 
If the abscess is very large, tracheotomy should be performed, and after 
Dr. Semon's tampon-canula (see Tracheal Instruments) has been inserted, 
the abscess should be opened in the ordinary way. 



CHRONIC LARYNGITIS. 

(Synonym: Chronic Catarrh of the Larynx.) 

Latin Eq. — Laryngitis chronica. 

French Eq. — Laryngite chronique. 

German Eq. — Chronischer Catarrh des Kehlkopfs. 

Italian Eq. — Laryngitide cronica. 

Definition. — Chronic inflammation of the lining membrane of the la- 
rynx characterized by hoarseness or loss of voice, and generally by more or 
less cough. Occasionally the malady causes thickening of the affected 
membrane, and sometimes leads to ulceration. 

Etiology. — The causes of this affection are the same as those indi- 
cated under the head of acute laryngitis, to which disease it often proves 
the sequel. It sometimes results from too prolonged use of the voice, es- 
pecially among clergymen and schoolmasters. The chronic forms of in- 
flammation also frequently extend from the pharynx, and the effects of 
continuity of texture are often seen in chronic alcoholism and the abuse 
of tobacco. It is commonly supposed that elongation of the uvula by 
mechanically irritating the epiglottis and orifice of the larynx is an almost 
certain cause of chronic laryngitis. I have seen several cases in which 
an obstinate and teasing cough, together with some congestion of the 
larynx, were apparently produced, or at least maintained, by an elon- 
gated uvula, the affection subsiding almost immediately after a portion had 
been snipped off: but on the whole I am inclined to agree with Ziemssen ! 
that the causal influence of this condition has been greatly overrated, and 
that Riihle 3 is correct in observing that the enlargement of the uvula and 
laryngeal malady are merely coexistent effects of the same cause — chronic 
pharyngitis. 

The influence of an atmosphere impregnated with atomic matter, in 
the production of disease, has long been recognized. In the last century, 
Bubbe, 3 Ramazinni, 4 and others, drew attention to this cause of morbid 

1 Cyclopaedia of Medicine, vol. iv. 

2 Die Kehlkopfkrankheiten, Berlin. 1861. 

3 Dissert. Inaugur., etc., Halae, 1721 ; Huf eland's Journ. vol., xcviii. p. 4. 

4 Abhandlungen von den Krankheiten der Kiinstler und Handwerker, translated by 
Ackermann, 1780, vol. i. pp. 123, 147; vol. ii. p. 27. 



CHRONIC LARYNGITIS. 208 

action, and in our own time, Holland, 1 Heussinger, 2 Virchow, 3 Lewin/ 
Headlam Greenhow, 5 and other physicians have further elucidated the 
subject. It need, therefore, only be observed here that the larynx suffers 
in common with the rest of the respiratory system in the case of needle 
grinders, pearl-button turners, and others who work in an impure atmos- 
phere, the chronic form of catarrh being especially common amongst per- 
sons so occupied. 

The great and sudden development of the larynx which takes place at 
puberty in males is often attended by chronic laryngitis, the so-called 
" cracked voice " of boys being always associated with marked congestion 
of the vocal cords. There seems also to be a rare constitutional condi- 
tion, where there is a tendency to chronic inflammation of many of the 
mucous canals. Seven such cases have come under my notice, all the pa- 
tients being men over fifty years of age. I had at one time a gentleman 
under my care who was suffering from chronic laryngitis, slight thicken- 
ing of the walls of the lower third of the oesophagus, gastro-intestinal de- 
rangement, and chronic cystitis. 

The influence of age and sex is very marked in cases of chronic laryn- 
gitis, adult males being by far the most common sufferers, and children 
the rarest. As a secondary phenomenon chronic laryngitis is, of course, 
almost invariably present in all long-continued diseases of the larynx, such 
as phthisis, syphilis, polypi, cancer, lupus, etc. 

tit/hiptoi/is. — The subjective symptoms of chronic laryngitis vary con- 
siderably under different conditions. When the patient refrains from 
using his voice, the local sensations are not very marked, some dryness 
and irritation in the throat, with occasional tickling cough, being all that 
is complained of. If the patient, however, exercises his voice for any 
length of time, these symptoms become much aggravated, and he is soon 
obliged to seek relief in silence. In some cases, in addition to the symp- 
toms above mentioned, a burning or pricking pain is felt, and there is 
often a frequent desire and effort to clear the throat. 

Objectively, the phenomena of chronic laryngitis consist in a marked 
alteration of voice and a slightly increased secretion, and in certain defi- 
nite anatomical changes. Impairment of the functions of the larynx is the 
most characteristic symptom of the disease. It varies in degree from 
slight modification in tone to complete loss of voice. It is characteristic 
also of this form of hoarseness in the early stage, that it is most marked 
when the organ has been at rest for some time. Thus, a patient with 
slight chronic congestion may be extremely hoarse on attempting to speak 
after an interval of silence, and yet the voice will become almost normal 
after the function has been exercised for a few minutes. The improve- 
ment probably depends on the quickened capillary circulation and stimu- 
lated nerve-force of the part, and has its analogy elsewhere. If, however, 
the patient continues to talk for a time, fatigue is experienced, and hoarse- 
ness or aphonia supervenes. In chronic laryngitis the voice is sometimes 
clear and natural in its ordinary tones, and the discordance is only observed 



1 Diseases of the Lungs from Mechanical Causes, and Inquiries into Conditions of 
Artisans exposed to the Inhalation of Dust, by Dr. Gr. Calvert Holland, London, 1843. 
1 Ueber anomale Kohlen- und Pigmentbildung, Eisenach. ls2:J. 

3 Anatomische Beschreibung der Krankheiten der Circulations- und Respirations- 
organe, Leipzig, 1841. 

4 Beitrage zur Inhalationstherapie in Krankheiten der Respirationsorgane, Berlin, 
1863. 

5 Chronic Bronchit's. London, 1870. 



210 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

when powerful exertions are made (as in singing, acting, public speaking, 
etc.). The cough is generally rather frequent, but it may amount to noth- 
ing more than " hawking," or " hemming," and sometimes it is almost en- 
tirely absent. In some cases, however, it constitutes the most trouble- 
some symptom. 

As regards secret Ion, the expectoration is never abundant, unless fhe 
laryngeal affection is complicated with bronchitis. The mucus discharged 
from the larynx is generally of a whitish gray color, and of viscid con- 
sistency, but in cases of long standing it is yellow, and after violent ex- 
acerbations of coughing, frequently appears streaked with blood. Res- 
piration is seldom much affected, but moist rales can generally be heard 
over the larynx. 

The laryngoscopie appearances are usually very marked, but vary con- 
siderably in different cases. A general or partial hyperemia is invariably 
present. The redness is generally suffused and fades off gradually into 
the healthy-colored membrane, but injection of the minute vessels is some- 
times apparent, especially on the epiglottis and vocal cords. On the for- 
mer the injection is usually arborescent, on the latter the arrangement 
of the vessels is generally linear, along the attached side of the vocal 
cord. Sometimes one vocal cord is seen to be bright red, whilst the 
other is of the usual white color, and the congestion may even be limited 
to a small portion of one cord. In the latter case it is always the outer 
attached portion of the cord which is congested. Small pellets of mucus 
are often seen sticking to different parts of the laryngeal membrane; and 
in cases of long standing, the whole surface of the larynx is frequently cov- 
ered with secretion. In some cases the mucous membrane, instead of pre- 
senting the velvety appearance which generally accompanies any pro- 
nounced congestion, looks dry and glistening. General tumefaction of the 
mucous membrane and submucosa is a very pronounced feature in inveterate 
cases, the epiglottis, ventricular glands, and inter-arytenoid fold all par- 
ticipating in a diffuse and uniform thickening. In the case of the vocal 
cords this change sometimes causes a granular condition of their surface, 
and often a very perceptible unevenness of their edges. Derangements in 
the mobility of the larynx may often be noticed. Some of these phe- 
nomena are of a mechanical nature, and depend on muscular action being 
clogged and impeded through the thickened state of the mucosa and sub- 
mucosa. Thus the hypertrophied inter-arytenoid fold prevents the nor- 
mal approximation of the arytenoid cartilages and vocal cords; while the 
swollen ventricular bands sometimes almost obliterate the ventricles of 
Morgagni, and, encroaching on the vocal cords, materially impede their 
movements. In addition, however, to these mechanical effects, true mus- 
cular pareses. of peripheral origin are often present; in such cases, as 
Ziemssen 1 observes, the paralysis is more often unilateral than bilateral. 
Where only one cord, however, is paralyzed, the impaired movement is 
made up for by increased activity on the part of its fellow, which is 
dragged across the middle line, beyond its usual range of movement. By 
this means approximation and phonation are secured, and in such instan- 
ces obliquity of the closed glottis can be seen with the laryngoscope. 

Erosions, or very fine shallow ulcerations, which extend no deeper 
than the epithelial layer, are not ^infrequently visible. Their most fre- 
quent seat is between the arytenoid cartilages and on the cartilaginous 
cords. Ulcerations, which pass through the whole thickness of the mu- 



1 Loc. cit. p. 216. 



CHRONIC LARYNGITIS. 211 

cous membrane, are of very rare occurrence in this affection, and peri- 
chondritis is very seldom met with, except in the subglottic regions. 

In addition to congestive swelling of the mucosa and submucosa, 
there occurs in some rare cases an organic thickening or hypertrophy of 
the soft structures. The epiglottis, ventricular bands, and ary-epiglottic 
folds are occasionally affected in this way. Lewin 1 has specially noticed 
the thickening of the ary-epiglottic folds in preachers. He attributes it 
to the forcible depression of the epiglottis by the contraction of the mus- 
cular fasciculi contained in the ary-epiglottic ligaments — a movement 
necessary to produce the deep, hollow tones which express pathos. It 
must be observed, however, that swelling of the ary-epiglottic folds is ex- 
ceedingly rare in this country except in laryngeal phthisis, and the inter- 
arvtenoid fold is far more frequently thickened; nodular excrescences, 
the result of chronic inflammation, are often met with. 

Pathology. — The disease is essentially a chronic inflammation of the 
lining membrane of the larynx, in which the vessels of the areolar tis- 
sue participate very little. Enlargement and tortuosity of the small ves- 
sels is found in cases of long-standing congestion, together with increase 
of the connective tissue, while the sub-epithelial portion of the mucosa 
is often converted into a lymphoid tissue. The latter by encroaching on 
the epithelium gives rise to the superficial erosions seen during life. 

Diagnosis. — An accurate opinion can only be formed by careful laryn- 
goscopy examination. It is of the first importance in every case of sup- 
posed chronic laryngitis to observe whether there is thickening, and if 
this condition exists, to determine whether it is due to inflammatory tume- 
faction, oedematous infiltration, or tuberculous deposit. In simple chro- 
nic laryngitis the natural contour of the parts is almost always preserved, 
but the coloration is somewhat redder than that of health. In oedema the 
swelling is generally of a bright color, and has a characteristic transpar- 
ent appearance; in phthisis, on the other hand, the thickened parts are 
usually of a dull color, though the surface may be accidentally congested; 
the swelling, also, as a rule, presents certain determinate forms, which 
will be described in treating of that disease. In all cases of chronic 
laryngitis of some months' standing the lungs must be most carefully ex- 
amined, the history of the patient and that of his family closely investi- 
gated, and his general condition inquired into, before a decided opinion 
as to the nature of the disease is given. 

Prognosis. — The tendency of the disease, when once fully established, 
is to remain stationary, or the symptoms may disappear for a short time 
and then recur. Under persistent local treatment and the careful avoid- 
ance of the exciting causes of the affection, however, recovery can gen- 
erally be secured. In old people the malady is always complicated with 
chronic bronchitis, and the symptoms of the latter affection mask and 
outweigh in importance the morbid phenomena dependent on the chronic 
laryngeal disease. Chronic laryngitis hardly ever terminates fatally, 
almost the only possibility of such an occurrence consisting in the super- 
vention of perichondritis, and such an issue is excessively rare, except 
when the disease occurs in the subglottic region. 

Treatment. — Local remedies of an astringent character are the most 
important agents in the treatment of chronic laryngitis. Any of the fol- 
lowing " Pigmenta " (Throat Hosp. Phar.) may be used: Ferri perchlor. 
(60 gr.), ferri persulph. (00 gr.), ferri sulph. (120 gr.), cupri sulph. (10 

1 Virchow's Archiv, Bd. xxiv. p. 429. 



212 DISEASES OF THE PHAUYNX, LARYNX, AND TRACHEA. 

gr.), zinci chlorid. (30 gr.), zinci acet. (5 gr.), zinci sulph. (10 gr.), alu- 
rninis (30 gr.), alum, chlor. (GO gr.), dissolved in an ounce of water or 
glycerine. The latter solvent, through its denser consistency, is better 
adapted for keeping up a prolonged action on the part. Solutions of the 
crystals of nitrate of silver were strongly recommended by Green ' in fol- 
licular cases, but they do not seem to me to act more beneficially than 
other mineral astringents. The solution of chloride of zinc is the remedy 
I most frequently employ; but provided the medicament is applied accu- 
rately and sufficiently often, it really matters very little which solution is 
used. The application should be made daily for the first seven days, on 
alternate days during the second and third week, twice in the third week, 
and so on, at gradually increasing intervals till a cure is effected. This 
is a general rule, but it must be modified according to circumstances. In 
cases where there is excessive secretion from the larynx (laryngorrhcea), 
the local application of turpentine sometimes does good, but these cases 
are generally very troublesome to treat. On the other hand, when there 
is long-standing hyperaemia, with diminished secretion — where the mucous 
membrane looks dry and shining — the remedy which I have found most 
successful is carbolic acid (from half a drachm to a drachm of the pure 
white carbolic acid to an ounce of glycerine). 

Another mode of applying astringent solutions to the larynx consists 
in the use of spray-producers (see page 182). For spray-inhalations the 
following remedies are most to be recommended, tannin being probablv 
the best of all; the proportions given are always for one ounce of water: 
— Tannin 1 to 5 gr. ; alum, 1 to 10 gr. ; perchloride of iron, -J to 2 gr. ; 
sulphate of zinc, 1 to 6 gr. ; chlori'de of zinc, 2 to 10 gr. Whichever solu- 
tion is selected, it should be employed three or four times a day for about 
five minutes. It must be understood, however, that this method of local 
treatment is generally only of service as a supplement to applications 
made with the brush. 

In many cases great benefit is derived from steam inhalations contain- 
ing some stimulating volatile principle. For this purpose the inhalations 
of pine oil, creasote, and juniper (Throat Hosp. Phar.) are among the 
best. Steam inhalations should, as a rule, be employed twice or three 
times daily for about ten minutes, at a temperature of 140°. 

When persistent congestion has led to pareses of the laryngeal mus- 
cles, the systematic employment of internal electricity is of the greatest 
value. In fact, cases of this class seldom yield to any other treatment. 

It is almost unnecessary to observe that the voice should be exercised 
as little as possible. For singers, actors, clergymen, and others, whose 
occupations require them to use the voice much, rest of the vocal organ is 
of the utmost importance. When complete silence cannot be enforced, 
the least possible exertion should be made in speaking — the patient should, 
in fact, whisper. If the uvula be much elongated it had better be ampu- 
tated. As the pharynx is almost invariably more or less affected, astrin- 
gent lozenges (Throat Hosp. Phar.) will be found very useful. Tannin, 
rhatany, and kino may often be prescribed in this form with great advan- 
tage. 

The waters of Ober-Salzbrunnen, Ems, and Selters are especially 
recommended by Niemeyer, 2 who observes that " we must accept the em- 
pirical facts that these waters relieve and cure very many cases of chronic 

1 On Bronchitis, New York, 184G. 

2 Lehrbuch der Spec. Pathol, u. Therap., 7te Aufl. p. 13. 



CHRONIC LARYNGITIS. 213 

laryngeal catarrh;" whilst French physicians praise the sulphuretted 
waters of the Pyrenees, especially of Les Eaux Bonnes, as being appro- 
priate to cases associated with granular pharynx. Several patients whom 
I have sent to the Pyrenean springs have derived undoubted benefit from 
the use of those waters, but, on the whole, I have seen more benefit re- 
sult from the waters of Aix-les-Bains and Marlioz. The climate of the 
Pyrenees is subtropical, and generally very ennervating in its effects on 
English patients. I can particularly recommend the hot sulphur-waters 
of Savoy when the voice remains weak and the mucosa is relaxed rather 
than congested. 

Where suitable atmospheric conditions cannot be selected the patient 
must wear a respirator, when the weather is at all cold or damp, and must 
protect the neck and body generally by warm and suitable clothing. Con- 
stitutional medicines and hygienic treatment will be necessary in some 
cases, and must vary according to circumstances. 



Chronic Glandular Laryngitis. 

This condition consists in an inflammation in which the minute race- 
mose glands are principally affected. It is almost always associated with 
follicular pharyngitis, 1 of which malady it generally constitutes a down- 
ward extension. It cannot, however, be called " follicular laryngitis," as 
the glands of the larynx are all of the racemose variety (Kolliker). The 
term " clergyman's sore throat " has been applied to it, but the clergy 
more often suffer from congestion of the whole mucous membrane and 
paresis of the laryngeal muscles. Although usually resulting from a pre- 
vious pharyngeal affection, it sometimes commences in the larynx, and 
afterward reaches the pharynx. It is often associated with indigestion, 
but whether there is any causal relation between the two conditions is 
uncertain. The symptoms are the same as those of simple chronic laryn- 
gitis, but perhaps milder — weakness of voice, fatigue after speaking, a 
constant inclination to clear the throat and swallow the saliva, or perform 
an act of deglutition, being the principal morbid phenomena. With the 
laryngoscope the enlarged orifices of the glands may sometimes be seen 
on the epiglottis and the posterior parts of the vocal cords as pale specks 
on the congested membrane, or as small red circles on the pale membrane. 
The other laryngeal appearances do not differ from those of simple laryn- 
gitis, except that the approximative action of the vocal cords is more 
often feeble and imperfect. There is frequently considerable constitutional 
debility. The treatment should, for the most part, be the same as for ordi- 
nary chronic laryngitis, but nitrate of silver (gr. xx. ad 3 j.) is more useful 
in this complaint, and the sulphur-waters of Aix-les-Bains are especially 
valuable. Constitutional remedies of an analeptic character are also gen- 
erally required. 



PlILERECTASIS LaRYNGEA. 

Venous congestion of the larynx is an extremely rare affection, and I 
have only met with four examples of it. It may depend on general or 
local causes, viz., it may occur " in persons affected with a morbid pre- 
ponderance of the venous system" (Hasse), or may be due to a local 



1 For a full description of this affection see Granular Pharyngitis, p. 23. 



214 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

strain. Duchek ' considers that the dilatation of the veins is one of the 
aggregate results of chronic catarrh. This is probably a mistake, seeing how 
rarely we meet with phlebectasis, and how common is chronic laryngitis. 
As a sequel to the latter affection, capillary engorgement of a passive 
character is often met with, but not mzo^s preponderance. The symptoms 
are generally slight; some alteration in the voice, an uneasy sensation in 
the larynx, and, perhaps, a more or less frequent cough, being the princi- 
pal morbid phenomena. The laryngoscopic appearances may be thus de- 
scribed: In mild cases, where the disease is very limited, extremely fine 
dark vessels may be seen running along the upper border of the ventricu- 
lar orifice and epiglottis. In more severe cases there is less regularity in 
the distribution of the distended veins, which may be observed in the 
ventricular bands, vocal cords, and arytenoid cartilages. Cases have come 
under my notice in w T hich streaks of blackened mucus adhering to the 
larynx have been mistaken for varicose veins — an error which needs only 
to be mentioned to be avoided. This condition of the larynx, indepen- 
dently of the inconvenience it occasions, is probably attended with some 
danger, as it most likely predisposes to passive oedema. Astringent solu- 
tions may do good, but the only treatment calculated to effect a perma- 
nent cure consists in destruction of the veins by electric cautery. 



Trachoma of the Vocal Cords. 

Very important organic lesions of the vocal cords are sometimes pro- 
duced in persistent cases of chronic laryngitis. Amongst these a rough- 
ness of their surface, apparently arising from a partial dermoid metamor- 
phosis of the mucous membrane, 2 is not uncommonly seen. This condition 
has been called chorditis tuberosa, 3 or trachoma of the vocal cords, and 
appears to consist in a hypertrophy of the connective tissue and a prolif- 
eration of its nuclei. 4 I have met with it most frequently in the case of 
singers. These cases are often extremely obstinate, and sometimes defy 
all treatment, but generally a prolonged course of local remedies of a 
strongly astringent (Ferri perchlor. 3 ij. ad 3 j.) or caustic nature (Ar- 
gent, nit. 5 j- ad 5 j.) in the end effects a cure. 



Subglottic Chronic Laryngitis. 

Chronic laryngitis in the subglottic region sometimes gives rise to con- 
siderable thickening of the tissues, especially at the under surface of the 
vocal cords. When the disease is well established the tumefaction often 
presents the appearance of a second vocal cord immediately below the true 
cord. Occasionally there is, so to speak, an interruption in the swelling, 
so that the projection can be seen below the vocal cord for a certain 
length, then a clear space, whilst further on the subcordal swelling is 
again apparent. The color of the hypertrophied tissue is generally whit- 
ish gray, but it is occasionally red ; the surface too, though usually 

' Virchow's Handbuch der speciellen Patkologie und Therapie. Abtheilung : Krank- 
heiten dea Larynx und der Trachea, p. 4 i » 2 

- Ziemssen's Cyclopaedia (Engl. tdit. ), vol. iv. p. 217. 

3 Tiirck : Klinik der Krank. d. Kehlkopfes, etc., Wien, 1866. 

4 Wedl. Ziemssen : Loc. cit. 



CHRONIC LARYNGITIS. 215 

smooth, is in rare cases more or less ulcerated. Hoarseness is the first 
symptom of the disease, but complete aphonia generally occurs at a com- 
paratively early period. Dyspnoea is also perceived as soon as there ia 
any considerable amount of thickening, and attacks of urgent suffocation 
sometimes occur. This symptom, as Catti ' has pointed out, results from 
the vocal cords becoming at parts agglutinated together by viscid mucus. 
Rokitansky 2 was the first to discover and describe this condition, and 
Czermak 3 shortly after published the details of a case in which he diag- 
nosed the affection in a scrofulous girl by means of the laryngoscope. 
Turck 4 published a case in I860, and SchefE 5 in 1871. In the same year 
Schroetter 6 reported three cases, and in 1873 Gerhardt 7 described the 
disease under the name of CJiorditis vocalis inferior hypertrophica. Since 
then Burow 8 has published six cases, in all of which tracheotomy was 
found necessary. Catti" has reported six cases, four of which were 
watched for a considerable time, and two only seen casually. In the 
former tracheotomy was found necessary in one instance. Other practi- 
tioners have also recorded cases, but the most important article on the 
subject is that lately written by Professor Schroetter 10 which contains a 
good resume of our present knowledge of the disease. 

Considerable doubt exists as to the exact nature of this affection, 
though in some cases the patients are of marked scrofulous constitution. 
The immediate local cause generally appears to be persistent inflamma- 
tion of the mucous membrane, and the swelling differs little from the 
hypertrophy of the inter-arytenoid fold and posterior wall of the larynx 
so frequently met with. Sometimes, as Schroetter points out, the affec- 
tion seems to originate in the cartilage or the perichondrium, those struc- 
tures being most frequently affected either just below the anterior com- 
missure of the vocal cords, or on the inner surface of the sides of the cri- 
coid cartilage — situations where, it must be remembered, the mucous 
membrane is in direct contact with the perichondrium, whilst in other 
parts the cartilage is more or less protected by the interposition of mus- 
cles. In each of the three cases in which I have had an opportunity of 
making a post-mortem examination there was disease of the cricoid car- 
tilage, and of one of the arytenoid cartilages. 

Ganghofner " thinks that the affection is only one of the symptoms 
of the curious disease which has been described by Stoerk 12 as "chronic 
blennorrhcea of the mucous membrane of the nose, larynx, and trachea." 
Although thickening in the subglottic region no doubt often takes 
place in the form of blennorrhoea just referred to, yet, on the other hand, 
it is certain that it very frequently occurs quite independently of that 
affection. Schroetter, with reason I think, objects to the term " chorditis 



I Allgem. Wiener Med. Zeitung, 1878. No. 39, u. f. 
*■ Jahrb. d. Path. Anat., iii. Aufl. bd. iii. § 1(5. 

3 Der Kehikopf spiegel und seine Verwerthung. f. Phys. und Med., ii. Aufl., Leip- 
zig, 186:}, § 87. 

4 Klink der Krankheiten des Kehlkopfs und der Luftrohre, Wien, 18G6, § 204. 

5 Wiener Med. Presse, No. 51, 1871, § 1813. 

6 Laryngol. Mittheilungen, Jahresbericht, etc., Wien, 1871 ; also Beitrag zur Be* 
handlung der Larynxstenosen, Wien, 1873. 

• Deutsch. Arch. f. Klin. Med., Bd. xi. 1873. 

s Langenbeck's Archiv. f. Klin. Chirurgie, bd. xviii. 1875, § 228. 

9 Op. cit. 

■" Monataschrift fur Ohrenheilkunde, etc., No. 12. 1878. 

II Ibid. 

12 Klinik der Krankheiten des Kehlkopfes, Halfte, i., Stuttgart, 1876. 



216 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

vocalis inferior hypertrophica," inasmuch as it localizes too narrowly a 
pathological condition which may affect any part of the larynx. Rokitansky 
considers the disease as an indurative metamorphosis of the mucosa and 
submucosa. 

Subglottic chronic laryngitis is not so rare as is generally supposed, 
for between lSG-i and 1872 nineteen cases came under the care of myself 
and colleagues at the Hospital for Diseases of the Throat, and I saw four 
cases at the London Hospital. 1 In every instance the disease was con- 
fined to the subcordal region, having been unilateral in sixteen cases, 
and bilateral in seven. But were I to include cases in which the inter- 
arytenoid fold was affected, together with the posterior portion of one or 
both of the vocal cords, I should be able to mention many more cases. In 
five of the twenty-three cases the swelling was partly translucent, and 
hence, no doubt, to some extent, oedematous, but in the remaining eigh- 
teen it appeared solid. 

When once the disease is fully established there is no difficulty in dis- 
tinguishing it, the only question which can arise is that which has refer- 
ence to the density of the swelling. In the oedematous cases the swelling 
is generally round in outline, resembling a nasal polypus, andean scarcely 
be mistaken for the more substantial form of hypertrophy. 

In all subglottic diseases the prognosis is relatively much more un- 
favorable than where the affection is suprnglottic. We see this in the 
case of benign growths, in oedema, and in cicatricial contractions. The 
difficulty of treating disease locally in this situation is so enormously in- 
creased that the more unfavorable prognosis will be readily intelligible. 
The prospect of the patient may be inferred from a brief reference to 
my twenty-three cases. In three of them Mr. Evans performed tracheo- 
tomy (186G), whilst in the previous year I opened the trachea in two 
cases referred to me by Dr. Patrick Fraser. Subsequently, between I860 
and 1872 (inclusive). I performed tracheotomy in five other similar cases. 
Of the nine patients operated on either by Mr. Evans or myself, two w r ere 
subsequently able to dispense with the canula, the subglottic obstruction 
having been got rid of mainly by the use of my dilator (Fig. 50, page 
192). Of the remaining seven, three died after fifteen months, nineteen 
months, and twenty-seven months respectively. Of the thirteen cases 
not operated on, four, I believe, died without tracheotomy, in five the 
swelling disappeared under treatment, and in four instances the disease 
remained stationary for some months, and I ultimately lost sight of the 
patients. I have found it necessary to perform tracheotomy much less 
frequently in recent years, a circumstance which I attribute to my much 
earlier recognition of the disease. 

Chronic laryngitis in the subglottic region should be treated with 
great assiduity, and, if possible, cured before any hypertrophy takes 
place. The plan of treatment recommended in the more common form 
of chronic laryngitis should be pursued, and if thickening occurs it should 
be met by the frequent passage of bougies or hollow vulcanite tubes, ac- 
cording to the plan laid down under Perichondritis. Even where there 
is considerable .dyspnoea this treatment may be pursued, for, as already 
pointed out, the shortness of breath in these cases is often caused by col- 
lections of viscid mucus. The mucus is dispelled by the catheterism, and 

1 I have seen a number of cases since 1872. but unfortunately have not, sufficiently 
detailed records to make use of them. My colleague. Dr. Whistler, informs me that 
he also not unfrequently mee:s with instances of the disease. 



CHRONIC (EDEMA OF THE LARYNX. 217 

the patient often obtains immediate relief. Scarification is often of great 
service, and electric cautery has been successfully employed by Voltolini. 1 
If, however, the dyspnoea becomes dangerous, tracheotomy must be per- 
formed. On recovery from the operation, dilatation of the larynx must 
be effected in the way hereinafter described. 



CHRONIC (EDEMA OF THE LARYNX. 

Latin Eq. — (Edema laryngis chronicum. 
Wench Eq. — (Edeme cronique du larynx. 
German Eq. — Chronisches Glottisodem. 

Italian Eq. — Edema cronico della laringe. 

Definition. — Serous orsero-purulent infiltration of the areolar tissue of 
the larynx, chronic in character, and generally occurring as a concomi- 
tant of some other local morbid condition, such as laryngeal phthisis, 
cancer, or syphilis. 

Etiology. — Chronic oedema of the larynx is frequently the sequel of 
the acute affection, and it is also a very common phenomenon in the 
course of serious structural changes of the larynx, such as occur in syph- 
ilis, laryngeal phthisis, and cancer. In the case of the two latter mala- 
dies, the primary affection being of an intractable nature, the associated 
oedema can only be regarded as a subject of pathological interest. In 
syphilis, however, although there may be great destruction of tissue, the 
fundamental disease is sometimes of less immediate importance than the 
infiltration to which it has given birth. I met with the affection 165 
times in 500 cases of laryngeal phthisis seen during life, but it was pres- 
ent in 71 per cent, of the cases examined after death. Sestier 2 found 
the condition due to laryngeal phthisis in 15 out of his 2 15 cases. In 1T9 
of my cases of tertiary syphilis of the larynx chronic oedema was present 
32 times ; it occurs in nearly every case of laryngeal cancer, as soon as 
the disease is well established. 

Symptoms. — The laryngoscopic appearances of chronic oedema are 
somewhat similar to those described in the section on acute oedema, but 
the picture of the disease is modified by the phenomena of the primary 
malady, as well as by its slower rate of progress. The mucous membrane 
is generally much paler than in acute oedema. The disease comes on so 
slowly, that the patient gets habituated to the insufficient supply of air, 
and often appears to be little embarrassed even when the lumen of the 
larynx is greatly diminished. 

Diagnosis. — A laryngoscopic examination at once reveals the condi- 
tion of the larynx. 

Prognosis. — This depends principally on the nature of the primary 
malady. Tuberculosis and cancer are necessarily fatal, but of course 
death may occur prematurely, through the intervention of serious oedema 

1 Monat«schrift fur Ohrenheilkunde, etc. , 1 878, No. 9. 

-'Op. cit. p. 103. Pulmonary phthisis was present in three other cases, but in 
these instances the oedema spread from an inflammatory or purulent point external to 
the larynx. 



218 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

of the larynx. On the other hand, in syphilitic cases, the secondary 
oedema is of more immediate importance than the radical disease, and the 
best result can often be obtained by appropriate treatment. 

Treatment. — Scarification is often of the greatest service in cases of 
phthisis and syphilis, but in cancer tracheotomy best promotes the com- 
fort of the patient, and the prolongation of his life. 



NON-MALIGNANT TUMORS OF THE LARYNX. 

(Synonyms: Benign Growths in the Larynx. Polypus of the 

Larynx.) 

Latin Eq. — Polypi laryngis. 

French Eq. — Polypes du larynx. 

German Eq. — Larynxpolypen. Kehlkopfpolypen. 

Italian Eq. — Polipi della laringe. 

Definition. — New formations of benign character, forming projections 
on the mucous membrane of the larynx, generally giving rise to aphonia 
or dysphonia, often to dyspnoea, and occasionally to dysphagia. 

History. — Isolated cases of laryngeal polypus are to be found at a 
comparatively early date, the case in which Koderik successfully ope- 
rated on a growth through the mouth, about the year 1750, 1 being one 
of the first described. Seventeen years later, Lieutaud 2 published 2 cases 
of undoubted laryngeal polypus. In 1833 Brauers, 3 of Louvain, attempted 
to remove a growth by thyrotomy. In 1836 Regnoli 4 recorded a case in 
which he extirpated a laryngeal growth through the mouth, after per- 
forming tracheotomy, and in the following year, Rvland 5 devoted several 
pages of his classical work to tumors of the larynx. It was not, however, 
until the year 1850 that a complete monograph appeared. Then it was 
that Ehrmann published his celebrated treatise 6 which included 31 cases 
of laryngeal growth. In the year 1851 7 Rokitansky brought forward 10 
additional cases; and in 1852 Dr. Horace Green, 8 of New York, published 
39 cases, 2 of which had occurred in his own practice. In the following 
year Dr. Gurdon Buck 9 collected 49 cases, including his own interesting ex- 
ample; and in 1854 Middledorpf 10 brought together 64 cases. Finally, in 
the year 1859, Prat published a case in which he had removed a growth 



1 George Herbiniaux : Parallele des differens Instruments, avec les Mt'thodes de 
s'en servir pour pratiquer la Ligature des Polypes dans la Matrice, en forme de Lettre 
a M. Roux, avec Figures. A la Have, chez Gosse et Percl., 1771. This case is 
quoted by Levvin : Deutsche Klinik, March 29, 1802. 

2 Historia Anatom. Med. , lib. iv. observ. 63, 64, 1767. 

3 Cited by Ehrmann. (See Note 6.) 

4 Osservazione Chirurg., etc., Pisa, 1836. 

5 A Treatise on the Diseases and Injuries of the Larynx and Trachea. 

6 Histoire des Polypes du Larynx, Strasbourg, 1850. 

7 Zeitschrift der k. k. Gesellschaft der Aerzte zu Wien, Marz, 1851. 

8 Polypi of the Larynx and (Edema of the Glottis, New York, 1852. 

9 Transactions of the American Medical Association, 1853. 

10 Die Galvanokaustik, Breslau, 1854. 



NON-MALIGNANT TUMORS OF THE LARYNX. 219 

through the thyrohyoid membrane. 1 Amongst all these cases there are 
only 9 in which an attempt was made to remove the growth during life, 
and one of these, viz., that by Koderik, already referred to, is so vague, 
that it must necessarily be excluded. 

On the invention of the laryngoscope, laryngeal growths were investi- 
gated with great zeal, and cases were soon published by Czermak, 2 Lewin, 3 
Gibb, 4 Fauvel, 5 Walker, 6 and others. In 1805 Professor von Bruns 7 is- 
sued a monograph containing IT cases, and in the following year Dr. 
Louis Elsberg 8 published a prize essay containing 13 cases. In 1868 von 
Bruns y reported 23 additional cases. In the year 1871 I published a 
work 10 containing 100 consecutive cases operated on by myself (from 1862 
to 18T0), and 189 other cases — being all the cases reported up to that time 
in medical literature. Here I may, perhaps, be allowed to observe paren- 
thetically, that I have since operated on 123 other patients (from May 
25, 1870, to December 31, 1878). The conclusions, as regards the eti- 
ology and nature of the growths drawn from my second series, being 
almost identical with those derived from the first set, I have not thought 
it necessary in this article to alter the various percentages formerly ar- 
rived at. I may mention, however, that owing to the more careful ex- 
clusion of malignant disease, the results, as regards the restoration of 
voice and absence of recurrence, have been more favorable in my recent 
cases. In 1872, Stoerk n published 3G cases operated on (1871 and 1872), 
and in 1871 Tobold ,2 reported 206 cases, with 70 operations (between 

1861 and 1871). In the same year Schnitzler 13 recorded 35 cases operated 
on (from 1872 to 1871). In 1875 Oertel 14 recorded 68 cases, 59 of which 
were operated on (between 1862 and 1871). In 1875 Schroetter 15 related 
81 cases, 18 of which were operated on (from 1870 to 1873). In 1876 
Hopmann 16 recorded 25 cases, with 18 operations (from 1870 to 1875). 
In the same year Fauvel 17 published 300 cases, with 220 operations (from 

1862 to 1875"). Between .1871 and 1876, Boecker ,8 published 10 opera- 
tions. In 1878 Paul Bruns 19 published a work on the relative merits of 
endo-laryngeal treatment and thyrotomy. This treatise is based on an 
examination of all the cases already referred to in this article, and includes 
besides 200 cases operated on by von Bruns (1868 to 1878), 35 cases ope- 



1 Gazette des Hopitaux, 1859, No. 103, p. 809. 

2 Wien. Med. Woohenschrift, January 8, 1859. 

3 Deutsche Klinik, 1862. 

4 Diseases of the Throat. Second edition. 

5 Du Laryngoscope au point de vue pratique, 1861. 

6 Lancet. November, 1861. 

I Die Laryngoskopie, etc., Tubingen, 1865. 

8 Morbid Growths within the Larynx, Philadelphia, 1866. 

9 Polypen des Kehlkopfs. Tubingen, 1868. 

10 Growths in the Laryux, London, 1871. 

II Laryngoscop. Operationen, Wien. 1871-72. 
18 Laryngoscopie, Berlin, 1874. 

13 Med. Presse, Wien, 1874. 

14 Deutsches Archiv fur Klin. Med., 1875. 

15 Laryngol. Mittheilungen : Jahresbericht der Klinik fiir Laryngoscopie, Wien, 1875. 

16 Deutsches Archiv fiir Klin. Medizin, 1876. 

11 Traite pratique des maladies du Larynx, Paris, 1876. 

15 Deutsche Klinik, Nos. 83-41, 1874 ; and Deutsche Med. Woohenschrift, No. 34, 
1876. 

| 9 Die Laryngotomie zur Entfernung intra-laryngealer Neubildungen, Berlin, 1878. 
Whilst making use of the original work, I have also availed myself of an excellent prS' 
cis, by Dr. Felix Semon (Medical Examiner, May 23 and 30, 1878). 



220 

rated on by Paul Bruns (1871 to 1878), and 75 other cases operated on 
by various laryngoscopists, amongst whom may be mentioned A. Burow, 
Labus, Navratil, Waldenburg, Voltolini, Beschorner, Schech, Sommer- 
brodt, Michel, Sidlo, Heinze, Halbertsma, Jelenffy, Scheff, Krishaber, Els- 
berg, Ruppaner, Hartman, and others. Since the issue of Paul Bruns' 
work, further cases have been published by Lefferts, 1 Clinton AVagner,* 
and others. 

Etiology. — Chronic congestion of the laryngeal mucous membrane is, 
far above all other causes, the most important etiological feature, in the 
production of simple morbid growths in the larynx. In some cases the 
disease appears to originate in an acute or subacute form of inflammation, 
but it is generally only as the starting-point of chronic hyperemia, that 
the more acute attack indirectly leads to the production of a new forma- 
tion. The most common cause of hyperemia is probably catarrh, and 
catarrh must therefore be looked upon as the great predisponent of 
growths. Neither syphilis, nor phthisis, nor any other constitutional con- 
dition, appears to favor the development of true growths, but both these 
dyscrasire — especially the tubercular — give rise to false excrescences or in- 
flammatory outgrowths. In cases of phthisis these formations, when 
present, occur at the posterior part of the larynx — generally on the inter- 
-arytenoid fold. "When a very protracted syphilitic congestion occurs, 
growths may arise; but this is a rare exception, and Dr. Harlan has well 
pointed out that few true laryngeal growths can be attributed to syphi- 
lis. 3 The fact, to be shortly referred to, that the affection is occasionally 
present at birth, makes it probable that a congenital predisposition to the 
disease may sometimes exist, though the neoplasm is not actually formed 
till adult or middle life. 

Some of the exanthemata, especially variola, scarlatina, measles, and 
en^sipelas, lead to the production of laryngeal polypi, by giving rise to 
chronic inflammation of the lining membrane of the larynx. 

The professional use of the voice is one of the circumstances most 
favorable to the development of growths, 21 per cent, of my patients old 
enough to have an occupation having been subject to this influence. 4 

Dr. Tobold 5 remarks that the affection is most common in middle life, 
from the thirtieth to the sixtieth year, and that laryngeal polypi are least 
frequently seen in childhood. Dr. Causit, 6 on the other hand, considers 
that they most frequently occur in early infancy. The latter author, in- 
deed, believes that the disease is very often congenital. But this mode 
of origin, though very probable in many cases, 7 has only been actually 
established in four, viz., one recorded by Dufours, 8 two cases in my own 
practice, 9 and one, the most important of all, reported by Dr. Arthur 
Edis. 10 In this case the child died from suffocation thirty-seven hours 
after birth, and a cyst about the size of a hazel nut was found in the la- 



1 Medical Record, February 9, 1878. 

8 Ohio Med. and Surg. Journ., 1878. 

s American Journal of Medical Science, vol. lii. p. 122. 

4 Growths in the Larynx, p. 16. 

1 Die chronischen Kehlkopfskrankheiten, Berlin, 1866, p. 200. 

6 Etudes sur les Polypes du Larynx. Paris, 1867. 

7 Paul Bruns considers that there are at least twenty-three cases on record in which 
the affection was congenital. (Op. cit. p. 177.) 

" Archives Generates de Med., Mars, 1867. 

9 Trans. Path. Soc, vol. xxv. p. 35. 

lu Trans. Obstet. Soc. , vol. xviii. p. 2. 



NON-MAJLIGNANT TUMORS OF THE LARYNX. 221 

rv tx. According to my experience, the middle period of life would ap- 
pear most favorable to the development of these neoplasms, and I find 
that after the age of fifty there is a considerable and sudden diminution 
in their number. In 100 cases treated in my own practice, the decennium 
of iortv to fifty furnished the greatest number of cases, whilst there were 
as many as seventy-two between the ages of twenty and fifty. On the 
other hand, there were only three patients over sixty. I have lately re- 
moved a papilloma from a woman aged seventy, in whose case the symp- 
toms of the affection had only existed a few months; but the greatest 
a^-e at which a growth has been seen occurred in the practice of Dr. Bruns, 
who met with a case in which the patient was seventy-four years old. 

Ad to the causal influence of sex, of my lOO patients, 62 were males 
and oa females. Of 187 patients in the practice of other operators, 135 
were males, and o2 females. 

Symptoms. — It will be readily understood, that, as a rule, the signs 
and symptoms of a growth in the larynx depend on the nature, on the 
exact situation, and on the size of the neoplasm. Thus a growth on the 
vocal cords causes aphonia or hoarseness; a growth on the epiglottis pro- 
duces dysphagia; and a large tumor, wherever situated, is likely to give 
rise to dyspnoea. 

The functional signs furnish very imperfect evidence, except to those 
who have had large experience of such cases. From the varying and 
peculiar character of the voice, the croupy cough, and the paroxysmal 
dyspnoea, the presence of a growth may be occasionally inferred by the 
experienced larvngologist; but those who have not met with many laryn- 
geal polypi would be rash to form a diagnosis from such symptoms. It 
must not be forgotten, however, that many years before the laryngoscope 
was invented, both Brauers and Ehrmann ! were able to diagnose growths 
with such accuracy, that they felt justified in opening the thyroid car- 
tilage. 

An alteration in the voice, though not invariably present, is the most 
constant symptom of a growth in the larynx. In my 100 tabulated cases, 
the voice was impaired ninety-two times; there being complete loss of 
voice in fifty-five cases, and hoarseness in thirty-seven. Impairment of 
voice was the only symptom in no less than 52 per cent, of my cases. As 
has been remarked by Czermak, a small growth often interferes with vo- 
calization more than a large one; for the small neoplasm, being almost 
always sessile, greatly modifies the vibration of the vocal cord to which 
it is attached, whilst a large one often becomes pedunculated as it grows, 
and by rising up into the cavity of the larynx, interferes very little with 
the normal formation of sound. Growths on the epiglottis and ary-epi- 
glottic folds do not generally affect the voice, unless they attain a very 
large size; and the same is not unfrequently true of small neoplasms on 
the ventricular bands. Growths below the vocal cords, on the other hand, 
by diminishing the column of air passing through the larynx, or by being 
forced up into the glottis in expiration, often cause aphonia. 

Patients with laryngeal growths do not, as a rule, suffer much from 
cough; but this symptom is occasionally so severe as to cause very great 
inconvenience, and it may even give rise to haemoptysis. The character 
of the cough depends upon the size and situation of the growth; it is gen- 
erally dry and hacking, and often aphonic. In young children, and in 
adults when the growth is very large and situated in the neighborhood 



Op. cit. : Cases xv. xxix. 



222 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

of the glottis, it has often a croupy character. In seven out of the 
twenty-six cases noticed by Dr. Causit it was described as "croupal." I 
have seen it occur also in two cases in violent paroxysms. 

Dyspnoea was present thirty times in my 100 cases, and was serious in 
fifteen cases. Difficulty of breathing occurred in about the same percent- 
age of the cases reported by other practitioners. 1 Most of the specimens of 
laryngeal growths in the metropolitan museums were taken from patients 
who died from suffocation; and in nearly all the cases reported in the medi- 
cal journals before the invention of the laryngoscope, dyspnoea was a prom- 
inent symptom. The difficulty of breathing is often paroxysmal. The ex- 
planation of this circumstance, as in many other cases of laryngeal obstruc- 
tion, is, that the patient is able to breathe well, even through a narrowed 
windpipe, provided that no further diminution suddenly occurs. If, however, 
the patient takes cold, and the mucous membrane becomes a little swollen, 
a paroxysm of dyspnoea may supervene. In the same manner, if the res- 
piration be hurried by exertion, an attack is likely to come on. Some- 
times, also, dyspnoea occurs suddenly, from the patient getting into an 
unusual position, and from the growth being consequently thrown more 
across the glottis. In one of my cases 2 the patient could only sleep with 
the hand resting under the neck; and if by chance her head slipped away 
during sleep, she immediately woke with a severe attack of dyspnoea. 
It almost invariably happens, that inspiration is much more difficult than 
expiration, and Lewin 3 has remarked, that the character of the respiration 
has a certain diagnostic value, as regards the seat of the growth. When 
inspiration is noisy and stridulous, and expiration comparatively easy, the 
growth is probably situated above the vocal cords, and vice versa. 

According to my own experience, actual pain is seldom caused by 
growths in or about the larynx, but uneasy sensations are occasionally 
felt. In only one of my 100 cases 4 was there decided pain, though in 
another 6 there was a sensation of oppression. Though patients rarely 
complain of a feeling of a foreign body in the larynx, they frequently 
have a disposition to clear the throat, as if to expel some accumulated 
mucus. I have most commonly met with tiiis symptom in cases of pe- 
dunculated growths, especially when they were attached to the vocal cords. 

Difficulty of swallowing does not generally occur, except when the 
growth springs from the epiglottis or where it attains a very large size; 
it is occasionally present, however, when the neoplasm arises from the 
arytenoid cartilages. In my 100 cases dysphagia was only present eight 
times, and in every instance 6 the epiglottis was the seat of the disease. 
In one case only 7 was there odynphagia. 

The physical signs are much more important than those of a functional 
character, and amongst them those observed with the laryngeal mirror 
stand pre-eminent. So complete is the information furnished by the 
laryngoscope, that were it not that there are certain rare and exceptional 
cases in which this instrument cannot be employed, the general semeio- 
logy would be useless. The situation of the growth can almost always 
be ascertained with the mirror, but in a few cases, where the growth is 
very large, the exact seat of origin may be concealed. The vocal cords 
are especially liable to be affected, these parts having been alone attacked 
in seventy-four of my cases, and suffering either alone or in conjunction 

1 Mackenzie : Op. eit. Appendix D. - Ibid. : Appendix A, Case 84. 

3 Deutsche Klinik, 1862. 4 Mackenzie : Op. cit. Appendix A, Case 97. 

5 Ibid. : Case 90. fi Ibid.: Case 83. 7 Ibid.: Case 28. 



NOTJ-MALIGXANT TUMORS OF THE LARYNX. 



223 



with other parts in no less than eighty-five cases. On the other hand, 
the arytenoid cartilages, with their folds of mucous membrane and second- 
ary cartilages, enjoy comparative immunity. 

The laryngoscopy appearance can best be described in detail, by sep- 
arating the different kinds of tumors, according to their pathological 
nature. 

PapiUomata (Figs. 54-56) are generally sessile, though occasionally 
pedunculated. They are often multiple, and sometimes occur symmetri- 




FiG. 54. — Papilloma in 
a Child a;t. eignt. 



Fig. 55. — Solitary Papilloma in 
an Adult. 




Fig. 50. — Multiple Papilloma 
in an Adult. 



cally. 1 They vary in size from a grain of mustard to a walnut, but they 
do not often attain the latter dimension. Their most common size is that 
of a large split pea. They are generally of a pink color, but they may be 
white, or even bright red. 

Fibromata (Fig 57) are usually round or oval, but occasionally are of 
a very divided form, not unlike cauliflower excrescences. 2 They are gen- 
erally, but not invariably, pedunculated. Their surface is usually smooth, 
but it may be rough, irregular, or wavy, and they are commonly of rather 
a bright red color. They are almost always single, and vary in size from 
a split pea to an acorn. 

Myxomata (Fig. 58) are very rare. In the single case 3 which I have 
met with, the neoplasm grew from the right vocal cord, and was only in 





Fig. 57. —Fibromata. 

part of a mucous character; this portion was seen with the laryngoscope 
to be quite transparent, and of a bright pink color. 

Cystic Tumors (Fig. 59) most frequently occur on the epiglottis, or 
spring from the ventricle of Morgagni. They are round, egg-like pro- 
jections, and, as they usually rise to some local irritation, are themselves 
red, and are surrounded by a hyperaemic area. 

Angiomata (Fig. 60). — The two growths of this kind which have come 
under my notice, were of a blackberry-like appearance, in color, form, 
and size; one grew in the right hyoid fossa, the other from the right ven- 



1 Mackenzie : Op. cit. : Appendix A, Cases 40 and 80. 

2 Ibid. : Cases 78 and 97. 

3 Ibid.: Case 99. 



224 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

tricular band. A similar growth has been observed in the former situation 
by Fauvel. 1 

Lipomata. — Tn the only case of lipoma on record 2 the growth was 
bi-lobate, of yellowish white color, and had a membranous pedicle, which 
appeared to project from the whole length of the ventricle. 

By means of the laryngeal sound the density, the size, and the exact 
origin of a growth may often be determined, "when with the laryngeal 





f*s 



Fig. o&. — Myxoma. 



Fiot 59.— Cyst. 



mirror alone there is still doubt as to these various points. A smooth 
growth may be either a fibroma or a lipoma; but whilst the former does 
not yield to pressure, the fatty growth is soft and resilient. The appear- 
ance of a laryngeal growth in the mirror is frequently deceptive, and it 
is often only by moving it with the sound, that its dimensions can be at 
all accurately determined. This is more especially the case, from the fact 
that only one surface of the tumor is visible in the mirror. Again, the in- 
sertion of a growth is sometimes hidden by the growth itself, and it is 
only by traction with the crochet that the precise origin can be ascer- 
tained. The various kinds of sounds and croch- 
ets which are useful are shown in Fig. 26, 
p. 179. 

Examination with the index-finger is of 
some value in those cases in which the growth 
is situated on the epiglottis, or the ary-epiglot- 
tic folds; but it may give fallacious results, 3 
and is seldom of any practical service where 
the tumor is attached at a lower level. 

By pressing the larynx upward with one 
hand on the thyroid cartilage, and by drawing forward the tongue with 
the other, the upper laryngeal orifice may occasionally be seen, and 
growths in this situation are thus sometimes visible. Voltolini 4 recom- 
mends that in addition to external manipulation and holding out the 
tongue, the fauces should be slightly irritated, so as to produce moderate 
retching. 

On auscultation of the larynx, when the growths are at all large, moist 
sibilant rales may be sometimes heard, but they are only characteristic of 
laryngeal obstruction. When the larynx is blocked up with growths, a 
dull sound is elicited on percussion. Small growths, however, do not in 
any way modify the usual resonance. It occasionally happens, especially 
in papillomatous growths, that small particles are expectorated, and, on 
microscopical examination, their nature can be verified. When this oc- 




Fig. 60.— Angiomata. 



1 Op. cit. p. 882. 

3 Growths in the Larynx, p. 204. 



2 Brims : Kehlkopfpolypen, p. 84. 

4 Berlin. Klin. Wochenschr., 1S68, No. 23. 



NON-MALIGNANT TUMORS OF THE LARYNX. 225 

curs in conjunction with other symptoms, it of course furnishes general 
evidence as to the nature of the disease; and when there is aphonia at 
the same time, it may be inferred that the growth is in the neighborhood 
of the vocal cords. 

In the early stages, the disease is purely local; but if the growth be- 
come large, it may, by embarrassing the respiration, or through other 
causes, give rise to constitutional disturbance; in this way, some amount 
of wasting and hectic may be caused, and these cases were formerly mis- 
taken for phthisis. Marked constitutional symptoms are, however, of ex- 
ceedingly rare occurrence. The various symptoms already described gen- 
erally develop themselves slowly, taking many months for their evolution. 
There is always a difficulty, however, in fixing upon the commencement of 
the disease, because the hyperemia, which generally precedes the growth 
of a tumor, gives rise to the same phenomena as the neoplasm itself. 
The progress of the case depends, of course, in a great measure, on the 
pathological nature of the neoplasm. After attaining a moderate degree 
of intensity, the symptoms often remain stationary, and it is surprising 
how long some patients — especially among the industrial classes — will suf- 
fer from aphonia before they seek relief. In one of my cases the patient 
had suffered from aphonia for twenty-four years, and another from dis- 
phonia for twenty-three years. On the other hand, if dyspnoea or dys- 
phagia be present, the patient is soon obliged to apply for medical aid. 

As a curious fact recorded in medical literature, rather than as having 
any practical bearing on the course of laryngeal growths, it may be re- 
marked, that there are a few instances l in which the disease has been cured 
by the accidental separation and expectoration of the entire neoplasm. 

Diagnosis. — The diseased conditions which might be mistaken for 
growths, are those occurring in syphilis, laryngeal phthisis, elephantiasis, 
lupus, malignant tumors, and outgrowths. Eversion of the ventricle 
might also give rise to an error in diagnosis. 

The condylomata of syphilis are seen as irregular, whitish, very slightly 
raised prominences on the congested membrane, the posterior wall of the 
larynx being their most common site. These formations are compara- 
tively rare, and when present, generally occur from six weeks to three 
months after the primary inoculation; they soon disappear under the use 
of mineral astringents. False excrescences are the result of syphilitic 
ulceration and subsequent cicatrization, and occur as irregular projections 
in different parts of the larynx. The gnmmata, which are occasionally 
found in the larynx, are so evidently deposits in the tissues, that they 
are not likely to be mistaken for true laryngeal growths. 

The thickening of laryngeal phthisis has not the defined character of 
a true laryngeal growth, and is generally soon followed by ulceration. 

In the few cases of lepra that have come under my notice, in which 
the larynx was affected, the mucous membrane covering the epiglottis 
was uniformly swollen. I believe that the disease never attacks the mu- 
cous membrane until after it has shown itself on the tegumentary surface. 
The thickening of lupus is generally very much like that which occurs in 
tertiary syphilis, and is usually soon followed by destructive ulceration. 

It is not always easy to distinguish between benign and malignant 
laryngeal growths; the latter, however, may be generally recognized by 
being more thoroughly blended with the surrounding tissues, and by be- 
ing very frequently ulcerated. In these cases, should particles be expec- 

1 Paul Bruna and Oertel : Op. cit. 
15 



226 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

torated, or removed during life with the aid of the laryngoscope, the 
microscope may afford useful information. 

Outgrowths, whether of cartilaginous, fibrous, or lymphoid character, 
are not likely to lead to mistaken diagnosis. It is true that the symp- 
toms are often similar to those caused by laryngeal growths, but when 
the laryngoscope is used, the entire absence of demarcation between the 
protuberance and the normal 4 tissues, in the case of outgrowths, is at 
once evident. When seen with the laryngeal mirror, they appear rather 
as non-inflammatory swellings or infiltrations than as defined tumors. A 
very characteristic case of this sort, in which the outgrowth was probably 
of fibrous character, is contained in my Jacksonian Prize Essay. 1 

Eversion of the ventricle is, perhaps, the only intelligible source of 
error, and this condition is extremely rare. I only know three such cases 
in the literature of medicine. Two 2 of these were only recognized on 
post-mortem examination, but in a third Dr. Lefferts, 3 of New York, at 
once diagnosed the disease with the mirror. 

Pathology. — Papillomata are by far the most frequent of all the be- 
nign growths in the larynx. In my 100 tabulated cases, sixty-seven were 
judged to be of this character. These growths occur at an earlier period 
of life than the other kinds of tumors, nearly all cases found in the first 
decennial period being papillomatous. 

Oertel 4 and Paul Bruns 5 distinguish three varieties, which show 
marked differences with regard to the interval occurring between the 
operation and the recurrence. The first class, consisting of light red or 
dark red tumors, varying in size from a millet-seed to a bean, with uneven 
surface and broad base, sometimes solitary, but generally thinly scattered, 
and never numerous, either does not recur at all, or only after some 
months. The second form, consisting of whitish gray exquisitely papil- 
lary, warty, or conical tumors, nearly always originating with a broad 
base from the vocal cords in adult patients, also recurs very slowly, often 
not till after several years. The third form consists of large reddish tu- 
mors resembling a mulberry or cauliflower. They may be solitary but 
are most frequently multiple, and are commonly seen in children. These 
growths generally recur after one or two months, and in three or four in- 
stances have been known to undergo epitheliomatous degeneration. In 
estimating the circumstances which govern the recurrence of papillomata, 
these differences, as well as the question, whether the papilloma has been 
radically extirpated, are to be considered. In several reported cases re- 
peated recurrences took place at the primary seat of the growth, which 
was evidently incompletely eradicated, but ultimately a complete cure 
was effected by the thorough removal of the new-grown papilloma. There 
is also a class of cases, in which papillomata appear, after removal of the 
primary tumor, on other, previously healthy, parts of the larynx. These 
are not exactly recurrences, nor due to the operation, but simply show 
that even complete removal does not afford any guarantee of permanent 
cure, if there be a tendency to the formation of papillomatous growths. 

Fibromata are of two kinds: (a) the firm and (b) the soft, and the 
former are twice as common as the latter, (a) Firm fibromata, though 
not nearly so common as papillomata, are next in order of frequency to 

1 MS. and Colored Drawing in the Library of the Royal College of Surgeons. 

2 Mackenzie : Op. cit. p. 34. 

3 New York Medical Record, June 3, 1876. 

4 Deutsches Archiv f ur klin. Medizin, Bd. xv. p. 290. 

5 Op. cit. 



NON-MALIGNANT TUMOKS OF THE LARYNX. 227 

those neoplasms. They were found to exist in 11 per cent, of my cases. 
The youngest patient affected was twenty-seven years of age, the oldest 
fifty-seven. In this class of neoplasm, the rate of growth is much slower 
than in the case of papillomata. Though generally situated in the sub- 
mucous tissue, fibromata are supposed to grow in some cases from the 
perichondrium; 1 when examined microscopically, they are seen to consist 
of bundles of white fibres, diverging and interlacing in various directions, 
and generally covered with several epithelial layers. These growths 
show no disposition to recur, (b) Soft fibromata consist of more or less 
perfectly developed fibro-cellular tissue, and have diffused through their 
substance a greater or less quantity of serous-like fluid. They are com- 
paratively rare in the larynx, being found in only 5 per cent, of my cases. 
The ages of the patients were 18, 21, 28, 30, and G5. In the few cases 
that have been seen, the rate of growth appears to have been rather slow. 
When removed, they have no disposition to recur. In each of my cases, 
also, there was only one growth. Trachomata (page 214), which are gen- 
erally considered in connection with chronic laryngitis, are closely allied 
to fibromata. 

Myxomata, or true mucous growths, are exceedingly rare in the la- 
rynx, and I have not myself met with a single instance in which a laryn- 
geal neoplasm was entirely of a myxomatous nature. 

Lipomata, or fatty tumors, are rarely found in the larynx, only one 
case, which occurred in the practice of Professor Bruns, 2 having hitherto 
been published. The epithelium was of a laminated character, consist- 
ing of about fifteen layers. The membranous envelope contained two 
oval fatty tumors, one about the size of a filbert, the other about half 
that size. The neoplasm also contained a small cartilaginous growth 
about the size of a hemp-seed, surrounded on all sides by connective 
tissue. 

Cystic Tumors are comparatively rare. Of my 100 tabulated cases, 
only two were of the true cystic character. Cases have also been re- 
ported by Virchow, 3 Bruns, 4 Durham, 5 Gerhardt, 6 Schroetter, 7 and Edis. 8 
These growths generally spring from the epiglottis or from one of the 
ventricles. They generally have dense walls, and are more or less com- 
pletely filled with thick, white, semi-fluid, sebaceous-like material, though 
sometimes the product is a thin yellowish or brown colloid fluid. Al- 
though, from our knowledge of other retention cysts, we might have an- 
ticipated that cystic tumors of the larynx would be likely to fill again, 
experience, so far as it goes, seems to show that when they have been 
thoroughly laid open, their contents emptied, and the cyst wall cauterized, 
there is no tendency to recurrence. 

Angiomata, or vascular tumors, are exceedingly rare in the larynx, 
and there is no evidence as to the tendency to recurrence. 

Compound Groieths are not unfrequent; indeed, it is often exceed- 
ingly difficult to determine to which class of neoplasms a given growth 
belongs. 

Other kinds of Growth. — Adenomata, or glandular tumors, are sel- 
dom met with in the larynx, though acinous gland-structure is often found 



1 Handbuch der spec, pathol. Anatomie, von Dr. August Foerster. Leipzig, 1854. 
■ Op. cit. 3 Die krankhaften Geschwiilste, vol. i. p. 246. 

4 Laryngoskopie, etc., Case xii. 5 Traus. Med.-Chir. Soc, vol. xlvii. 1864. 

8 Ziemssen's Cyclopaedia, vol. vii. p. 889. 
3 Op. cit. 8 Loc. cit. 



228 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

in papillary growths; * occasionally, however, the entire neoplasm consists 
of an hypertrophied racemose gland. It may perhaps be as well to remark 
here that hydatids are stated to have been found in the larynx. 2 Ryland 3 
states, that "a case of this sort, developed in one of the ventricles of the 
larynx, has been known to project so far into the cavity of this organ, as 
to give rise to all the symptoms which usually attend a foreign body there." 
On this subject, Foerster observes, 4 that "mucous polypi were described 
as hydatids, by the older authors." Ryland also refers to cases of cartila- 
ginous tumors of the larynx; but the examination of these growths was 
made at a period (1835) when histology was quite in its infancy, and the 
account, therefore, is not of much value. Rokitansky does not mention 
the occurrence of cartilaginous tumors in the larynx, but Virchow, 5 limit- 
ing the term of Enchondroma to heterologous growths, and describing' 
those cartilaginous tumors, which arise in connection with pre-existing car- 
tilage, as Ecchondroses, especially calls attention to the occurrence of the 
latter in the larynx, and remarks that " whether arising from the thyroid 
or cricoid cartilage, they generally grew toward the cavity of the larynx." 
This is not, however, invariably the case, for in a specimen which I exhi- 
bited at the Pathological Society,' a growth about the size of a bantam's 
egg, originating from the cricoid cartilage, extended downward and for- 
ward in front of the trachea. "The cartilaginous outgrowths," says Vir- 
chow, " are sometimes broad and flat, sometimes circumscribed and nodu- 
lar. On examining the larynx (with the laryngoscope), an outgrowth of 
this sort, as it has an epithelial covering, is easily mistaken for a polypus, 
and at the present time, when laryngeal growths are studied with so much 
interest, these cases deserve special notice, as, from their thickness and 
hardness, a'ny operation, carried out per vias naturales is altogether im- 
possible." Professor von Bruns 7 operated on two cases of laryngeal 
growth, in which the neoplasm w T as proved to consist of thyroid-gland tis- 
sue, the disease being probably allied to the so-called struma accessoria of 
Albers. 8 

Degeneration of Growths. — Laryngeal neoplasms, with the exception 
of some very rare forms of papillomata, which may become cancerous, ex- 
hibit little tendency to retrogressive changes. Occasionally, but most in- 
frequently, the papillary growths undergo fatty degeneration, and proba- 
bly in those few cases in which spontaneous expulsion of the neoplasm 
has taken place, this change had previously occurred. Caustics may per- 
haps, in some cases, promote these degenerative evolutions. Sometimes 
the neoplasms undergo amyloid degenerations, and the cases of amyloid 
growth reported by Dr. Ernst Burow, 9 and Ziegler, 10 probably originated 
in this way. 

Prognosis. — The tendency to death being by suffocation, and the most 
common symptoms caused by a growth in the larynx being dysphonia, the 

1 The reverse of this is stated by Drs. Cornil and Ranvier in their useful little Ma- 
nuel d'Histologie pathologique, p. 289 ; but Dr. Andrew Clark has repeatedly found por- 
tions of racemose glands in the growths I have removed. 

2 Andral : Anat. Pathol. , Translation, vol. ii. p. 459. 

3 Ryland : Diseases of the Larynx, p. 226. 

4 Foerster : Op. cit. p. 210. 

5 Op. cit. p. 438 et seq. 

6 Transactions of the Pathological Society, vol. xxi. p. 58. 

7 Paul Bruns : Op. cit. p. 201. 

8 Virchow's Krankhaften Geschwiilste, Twenty-second Lecture, p. 13. 

9 Laryngoscop. Atlas, Stuttgart, 1877. 

10 Virchow's Archiv, vol. xlv. p. 1. 



NON-MALIGNANT TUMORS OF THE LARYNX. 229 

prognosis has to be considered in relation to these two circumstances. In 
the few cases in which dysphagia is present, the neoplasm is generally at- 
tached to the epiglottis, and can therefore be easily removed. Under these 
•circumstances a favorable prognosis may be given. 

(a) In relation to Life. — Growths in the larynx which cannot be re- 
moved with the aid of the laryngoscope are always attended with danger 
to life, which is either immediate or remote, according as the neoplasm is 
large or small. The gravity of the prognosis is also affected by the age 
of the patient, the disease being, cceteris paribus, less dangerous in the 
<jase of adults than young children. 

In adults death is not likely to take place from suffocation, unless the 
patient refuses to submit to proper treatment. Of coarse, if tracheotomy 
is performed, the peril of suffocation is at once avoided; but it must not 
be forgotten that, even in opening the windpipe, there is a very slight, 
though still an appreciable, risk. The disposition to bronchitis, which is 
■often the immediate result of tracheotomy, when prolonged dyspnoea has 
prevailed, must also be taken into consideration. 

In children, as the larynx is much smaller, the disposition to spasm is 
much greater, and not only treatment, but even accurate diagnosis, is 
much more difficult. The presence of a growth also predisposes to laryn- 
geal affections, such as catarrhal laryngitis, and possibly laryngismus, 
whilst in the presence of epidemic diphtheria, the child with a laryngeal 
neoplasm is more likely to be attacked, and less likely to recover. In chil- 
dren also the prospect in relation to tracheotomy, both as regards the oper- 
ation itself and its immediate results, is less favorable than in the case of 
adults. The prognosis, therefore, as regards a fatal termination, is more 
serious. 

(b) In relation to Voice. — As regards the voice, a favorable opinion 
may, as a rule, be given if laryngoscopic treatment can be employed. If 
the fauces be not abnormally sensitive, if the upper opening of the larynx 
be of average size, if the growth be single, and if it be pedunculated, there 
is every probability that the voice will be restored. If the opposite con- 
ditions prevail, the prognosis is less favorable. When the growths are 
sessile, very numerous, and apparently closely incorporated with the sub- 
jacent tissues, the prospect of restoring the voice is extremely doubtful. 

In giving an opinion as to the ultimate result of these cases, even when 
treatment is adopted with success, the disposition to recurrence must not 
be forgotten. In the section on Pathology, it may be seen that whilst 
some forms of papillomata show a continual disposition to reproduction, 
•other laryngeal growths, with the exception of fasciculated sarcomata, sel- 
-dom occur. 

Treatment. — Before considering the subject of treatment, it may be 
well to observe that there are a few cases in which operative procedure is 
not required. Thus small growths on the epiglottis, or ventricular bands, 
which cause little or no inconvenience, may well be left alone. This re- 
mark especially applies to fibromata, which grow much less quickly and 
.are more frequently arrested in their development than other growths. 
In these cases, all that is necessary is to make a periodical examination of 
the larynx, once or twice a year, to see that the neoplasm does not increase 
in size. Several cases have come under my observation, during the last 
twenty years, in which small warts, after attaining a certain size, have not 
undergone any further development. Further, it sometimes happens, that 
the neoplasm is not sufficiently defined to admit of its removal, and in 
some cases, where, in consequence of the advanced age or occupation of 



230 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

the patient, the voice is of little importance, no treatment need be adopted 
unless the respiration be also affected. 

But before discussing the various kinds of treatment, it will be well to 
inquire whether any possible evil can result from endo-laryngeal opera- 
tions. The principal points for consideration are the following: 1. Does 
the operation ever cause such an amount of inflammation as to necessitate 
tracheotomy ? 2. Does perichondritis or necrosis of the cartilages ever 
result from these operations? 3. Does a benign growth ever become ma- 
lignant under the influence of laryngoscopic operations? 

1. Since I have taught laryngoscopy, many young practitioners have 
learnt to remove growths under my supervision, and though of course 
these early operations are often unsuccessful, I am not aware of a single 
instance in which any violent inflammation has been thus set up, or any 
serious injury done to the larynx. Cases, however, occasionally occur in 
which bad results may appear to follow laryngoscopic treatment. Thus a 
patient may present himself with a large growth nearly blocking up the 
glottis, but with little dyspnoea. Now it must be remembered, that such 
a patient is in imminent danger of death; a slight catarrh, a crumb of 
bread going the wrong way, or a paroxysm of coughing may choke him 
in a few seconds. The question thus arises in these cases whether we 
should perform tracheotomy at once, and subsequently remove the growths 
by endo-laryngeal treatment, or whether we should try the endo-laryngeal 
method in the first instance. It must be clearly understood that, if the 
endo-laryngeal operation is not successful, it is certain to precipitate tra- 
cheotomy, and that a patient who, though on the brink of suffocation, 
might have postponed the operation for several weeks — possibly for months 
— may require to have his windpipe opened in a few hours or even sooner. 
Under such circumstances the patient and his friends — possibly even the 
medical attendant if he has not carefully studied the peculiar contingen- 
cies of the case — may suppose that the rashness of the operator has neces- 
sitated an extra-laryngeal operation which would not otherwise have been 
called for. On the other hand, if the operator had at once proclaimed the 
necessity of tracheotomy, he would have been free from blame in the minds 
of those looking on. Nevertheless the duty of the laryngoscopist, under 
the circumstances referred to, is clearly to try the endo-laryngeal method 
in the first instance, after fully explaining the situation to the patient. I 
can recall many instances, in my own practice, in which tracheotomy has 
thus been altogether avoided, cases, indeed, in which I scarcely suppose it 
possible to operate without being obliged to open the windpipe precipi- 
tately. In three instances, however, of large growths, in which endo-laryn- 
geal methods were attempted, I found it necessary to perform tracheotomy 
a few hours — in one instance two hours — later. 

2. As regards the development of perichondritis, I am not aware of 
any instance in which this condition has resulted from an endo-laryngeal 
operation. In one of my cases, 1 in which the left vocal cord was immo- 
bile before the growth was touched, on the removal of the growth from the 
anterior commissure of the vocal cords, the abductive action of the left 
cord was seen to be defective, and four months later tracheotomy became 
necessary. After wearing the tube for eighteen months the patient died. 
On post-mortem examination the posterior plate of the posterior zcall of 
the cricoid cartilage was found to be diseased, and there was a fistulous 

1 Op. cit., Case 73. 



NON-MALIGNANT TUMORS OF THE LARYNX. 231 

communication at the base of the cartilage between the food and air-pas- 
sages. The history of this case points to the probable origin of the dis- 
ease in the cricoid cartilage at a date antecedent to any laryngoscopic 
treatment; and I would call attention to the fact that the part operated 
on — the anterior commissure of the larynx — was within the larynx, whilst 
the necrosed cartilage may almost be said to have been without that organ, 
and nearlv an inch from the seat of the growth. 

3. As regards the question of the conversion of benign into malig- 
nant growths, I may mention that in my first series of growths there was 
one case ' which at first was believed to be papillomatous, but subse- 
quently proved to be an epithelioma. In this case, the full details of 
which will be found in my work, the patient's throat was so irritable that 
only three laryngoscopic seances were attempted, and I only once suc- 
ceeded in passing forceps into the larynx. As the whole growth was 
subsequently removed by thyrotomy, I cannot imagine that the single 
endo-laryngeal operation could have converted a benign into a malignant 
growth. The whole subject has recently been so ably discussed by an- 
other physician a that I cannot do better than make use of his observa- 
tions. Whilst allowing that benig-n growths sometimes assume a malio*- 
nant character in the entire absence of surgical interference, the writer 
calls attention in this respect to Virchow's 3 opinions, who admits that 
persistent irritation of healthy tissues may lead to the formation of heter- 
oplastic growths. The author justly maintains, moreover, that the degen- 
eration of benign into malignant neoplasms never takes place except 
when there is an inclination to constitutional vice ; and he points out 
that under these circumstances the change may take place, with or with- 
out surgical interference. He further remarks that even frequently 
repeated local irritation does not produce degeneration. This has been 
most noticeable in those cases in which, in consequence of repeated 
recurrences, laryngoscopic treatment has had to be recommenced de novo 
many times, sometimes even on four, five, or six occasions, until finally a 
complete cure was obtained. 

In some cases of growth, especially in recurrent papillomata, I have 
operated from time to time for many years without ever observing any 
malignant degeneration. Indeed, in the many hundred cases of papillo- 
mata that have been operated on, I only know of three instances (Gibb, 
Mackenzie, and Rumbold), in which growths originally benign afterward 
assumed a malignant character. I am not aware that there is the slight- 
est evidence that in any one case treatment exercised an unfavorable 
iniluence. 

Were, however, the conclusions on the above points of quite an 
opposite character, the symptoms are often so inconvenient and some- 
times so dangerous, that in bv far the greater number of cases that come 
under notice, it would still be necessary to adopt measures for the re- 
moval of the growth, or for the relief of the symptoms it causes. These 
measures may be either palliative or radical. 

Palliative treatment consists in placing the patient in such a condition 
as to relieve him of immediate danger to life. This plan of treatment is 

'Op. cit., Case 87, p. 183. 

2 London Medical Record, November 15, 1878, p. 495. (The article in question is 
anonymous, but I believe that the author is Dr. Felix Semon.) 

3 Die krankhaften Geschwiilste. Bd. i. p. 349. 



232 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

called for in all cases where the growth greatly interferes with respira- 
tion, where for any reason laryngoscopic treatment cannot be carried 
out, and where the patient is unwilling to permit an extra-laryngeal 
operation. The only safe palliative treatment consists, of course, in the 
operation of tracheotomy, and it must be recollected that this operation 
affords absolute protection only as regards death from suffocation. 
When growths situated in the cavity of the larynx attain a very large 
size, they are apt, after a time, to interfere with deglutition. In such 
cases, therefore, though tracheotomy may have removed the original 
source of danger, at a later stage progressive dysphagia may occur. 

Radical treatment may be conducted either internally, through the 
natural upper orifice of the larynx, that is, with the aid of the laryngo- 
scope ; or externally, or by direct incision into the larynx ; or by the 
combined method, tracheotomy being first performed, to place the patient 
in a condition of safety, and the growth being subsequently removed 
through the mouth. 

The Removal of Growths by Endo-laryngecd Treatment. — This me- 
thod represents, perhaps, the greatest triumph which the laryngoscope 
has effected. No danger is incurred, little or no pain is felt, and scarcely 
a drop of blood is lost, whilst the long-lost function of a most delicate 
organ may be almost instantly restored, and a morbid condition, threat- 
ening the immediate extinction of life, may be at once and for ever re- 
moved. 

The removal of growths from the larynx requires ingenuity on the 
part of the operator in overcoming difficulties by means of mechanical 
contrivances, but above all, perhaps, the intelligent co-operation of the 
patient. Although greater eclat is often derived from the removal of a 
large growth than a small one, it will be readily understood, that, caeteris 
paribus, the smaller the growth the greater the difficulty of its removal. 
As a rule, a growth of moderate dimensions — that is, one between the 
size of a horse-bean and a Barcelona nut — is most easily seized. Of 
course, the difficulty partly depends on situation, the posterior portion of 
the glottis being more accessible than the anterior, and the upper part of 
the larynx than the lower. The difficulty is immensely increased when the 
growth is situated below the vocal cords. 

Several different kinds of Instruments, and indeed different modes of 
treatment, are often required in the same case. It is obvious that certain 
kinds of instruments are better adapted for certain kinds of growths : 
thus the short sessile growths — the most common in the larynx — can be 
most easily removed with forceps ; cystic tumors only require incision, 
and small fibromata may frequently be treated by division of their base. 
On the other hand, pedunculated growths are favorable to the use of 
wire-loops, ecraseurs, and guillotines. 

Endo -laryngeal treatment may be either mechanical or chemical, and 
though in practice it is sometimes necessary to combine these methods, it 
will be found most convenient to consider them separately. 

Mechanical treatment maybe accomplished (1) by evulsion; (2) by 
crushing ; and (3) by cutting. I have not thought it necessary to sub- 
divide the last-named process into excision, abscission, and incision, as it 
would lead to useless repetition. 

Before commencing treatment, some previous preparation is required 
in many cases. Congestion of the fauces, elongation of the uvula, 
enlarged tonsils, and hyperamiia of the larynx, must, if possible, be first 
subdued by appropriate remedies. Unless the congestion of the larynx 



NON-MALIGNANT TUMORS OF THE LARYNX. 233 

"be very considerable, it need not be taken into account, but if there be 
active inflammation, any operative procedure would be likely to aggra- 
vate the mischief, and render tracheotomy necessary. It is also quite 
useless to attempt any delicate operation on the larynx while the uvula is 
greatly elongated or the tonsils much enlarged. 

In order to facilitate endo-laryngeal operations, various procedures 
have been recommended for producing anaesthesia of the pharynx and 
larynx. It is unnecessary, however, to describe the various means 
recommended, such as the application of chloroform, morphia, etc., to 
the internal parts, the administration of opiates, bromide of potassium, 
etc., as I have never found any of them of the least use, and some are 
even dangerous in their effects. 

Patients cannot, as a rule, be operated on under chloroform, unless 
tracheotomy has been previously performed, or unless the growth is 
within reach of the finger, or external to the larynx, viz., in the hyoid 
fossa or on the posterior surface of the cricoid cartilage. By inhaling a 
few whiffs of chloroform, however, before treatment is commenced, the 
larynx is sometimes rendered less sensitive. By sucking ice, also, for 
a, few minutes before the operation, laryngoscopic treatment is more 
easily borne. 

When the epiglottis is long, and hangs obliquely, it sometimes hin- 
ders operations on the larynx, and several instruments have been invented 
for raising it. Some Continental practitioners even go so far as to pass 
a thread through the valve, and cause it to be held back by an assistant 
during the operation. Though such instruments may be useful for pur- 
poses of diagnosis, I have not found them applicable where operations 
have been necessary. 

Before introducing instruments into the larynx, they should always 
be warmed. This precaution should never be omitted, as it greatly dim- 
inishes the irritation naturally caused by the use of instruments in the 
larynx. 

As no practitioner would attempt to remove growths without being 
thoroughly skilled in the use of the laryngoscope and in the application 
of remedies to the larynx, it is unnecessary to enter into minute details 
#s to the precise mode of carrying out the operation. I may, however, 
observe that as, when an assistant holds out the patient's tongue, his 
hand and arm are apt to get in the way, and the tongue is likely to be 
drawn to one side, the patient should hold out his tongue himself. In 
the same way, if it can be avoided, I do not employ an assistant to 
steady the head ; for this purpose, all that is required is a chair with a 
high perpendicular back and narrow seat. 

(1.) Evulsion is effected with forceps, and is applicable to all growths, 
except those of cystic character. Cysts have indeed been torn away ; 
but this is only possible where the walls are thin and membranous. This 
method is particularly suitable in cases of sessile growths, for here other 
modes of treatment are difficult, and the softer the growth, the more 
favorable it is for removal by evulsion. I am in the habit of removing 
growths with two kinds of forceps, viz., the common laryngeal forceps 
and the tube-forceps. 

(2.) Crushing can be carried out with either of the two kinds of 
forceps already described, and was used, in conjunction with other 
methods, in 3 of my 100 cases ; it has also been employed by Lindwurm, 
Schroetter, Tiirck, and others. I formerly employed this plan of treat- 
ment in cases in which the growth was of dense structure, and very 



234 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

firmly attached ; but latterly I have generally used cutting instrument* 
in these cases. Crushing, however, is preferable to using force in evul- 
sion. As a rule, the stronger kind of forceps are required ; but the 
blades should be natter, i. e., less spoon-shaped, and rougher, than for 
evulsion. The American translator of Dr. Tobold's work describes the 
process as " crushing up," and observes, that energetic and repeated 
compression of the tissue is all that is required to destroy the conditions 
of nutrition and produce mortification, and that subsequently the dead 
portion can be separated. It is probable that, in many cases, wher« 
evulsion is adopted, crushing takes place at the same time ; in other 
words, that, when a growth is torn away, its base is, to a greater or less 
extent, lacerated and crushed. The success of evulsion must, therefore,, 
in part, be attributed to the incidental crushing which takes place. 

(3.) Cutting may be carried on, as already remarked, either by exci- 
sion, abscission, or incision. For excision, cutting forceps are used; ab- 
scission may be performed by means of knives, scissors, guillotines, or 
ecraseurs; while for incision, or scarification, knives or lancets are em- 
ployed. 

I now remove almost all growths with my cutting forceps and rarely 
make use of knives, scissors, or other instruments. Only very small guil- 
lotines can be used, and only a very small portion of a growth can, as a 
rule, be sliced off. I have never been able to employ these instruments- 
with advantage. 

Voltolini 1 has pointed out that soft pedunculated growths maybe 
torn away by frequent up-and-down movements of a sponge passed into 
the larynx. Some years ago I removed a growth from the larynx of a 
child (on whom I was unable to use the mirror to guide the hand) with a 
miniature ramoneur (see Oesophageal Instruments). In such cases I think 
my croup-brush (p. 180) might prove useful. 

Chemical Treatment. — Chemical treatment may be carried out either 
with caustics, escharotics, or galvanic cautery. 

Caustics. — Solutions of nitrate of silver are generally of but little use;, 
if employed, however, they should be exceedingly concentrated, and should 
be accurately applied, with a very fine camel's hair pencil, to the seat of 
disease. On reference to my own cases, 2 but especially to those treated 
by other practitioners, 3 it will be seen that when laryngoscopy was first 
introduced, growths were generally treated by the application of caustics. 
This was no doubt due to the circumstance that practitioners were not 
then yet aware to how great an extent operations could be conducted. 
within the larynx, and at that time, of course, no great manual dexterity in 
this department had been acquired. The small utility of this treatment 
is, however, demonstrated by the fact that since 1862 mechanical methods 
have almost entirely superseded the local application of caustics. Never- 
theless, there are some cases in which caustics can be usefully employed. 
Thus in treating cystic growths, it is a good plan to apply caustic to the 
interior, after an incision has been made, and the contents of the cyst 
evacuated. 

Again, for the prevention of recurrence after the removal of papillary 
growths, Fauvel 4 recommends the insufflation of a powder consisting of 
equal parts of savine and alum. 

1 Monatsschrift fiir Ohrenheilkunde, etc. No. 2, 1877. See also Nos. 3 and 8,. 
1878. and No. 1, 1879. 

2 Op. cit., Appendices A and C. 8 Ibid., Appendix D. 4 Op. cit. p. 256.. 



NON-MALIGNANT TUMORS OF THE LARYNX. 23S 

Escharotics. — On a few occasions I have employed escharotics with 
marked success, but only in a supplementary way. They may be used in 
cases where numerous small growths cover a large surface of the mucous 
membrane of the larynx. 1 I have occasionally employed nitric acid, but 
the escharotic which I have found most useful is " London paste " (Throat 
Hosp. Phar.). To all caustics and escharotics, however, the objection re- 
mains, that if sufficiently powerful to be effective, they are very likely to 
cause spasm of the glottis, or to give rise to inflammation of the adjacent 
mucous membrane; for this reason I now very seldom use them. 

Galvanic Cautery. — Galvanic cautery may be carried out, either with 
knife-like instruments, or with loops. This plan of treatment was first 
practised by Professor Middledorpf, 2 and has since been very successfully 
carried out by Drs. Voltolini, 3 of Breslau, and other practitioners; but I 
cannot say that I have found it well adapted for the destruction of laryn- 
geal growths. 

Extra Laryngeal Methods of Removing Growths. — In certain cases, 
it unfortunately happens that growths in the larynx cannot be removed 
through the mouth. 

The difficulty of laryngoscopic treatment may be due to the large size 
or extreme density of a growth, to its inaccessible situation, or extensive 
origin; to the occurrence of inflammatory tumefaction, or spasm of the 
glottis, on attempted evulsion through the mouth; to great irritability of 
the fauces, or to an unusually nervous and excitable state of the patient. 
In the case of very young children also, an extra-laryngeal method may 
be necessary. 

The large size of a growth does not, in itself, call for external treat- 
ment, some of the largest growths having been removed per vias natu- 
rales.* The extreme density of a growth sometimes presents a great diffi- 
culty to laryngoscopic treatment, but with strong cutting forceps, this 
difficulty is only insuperable in the case of ecchondroses, and it is very 
questionable whether radical treatment should be attempted for their re- 
moval. The growth may be so situated that it cannot be completely 
eradicated from above. This occasionally happens in the case of growths 
springing from the anterior wall of the larynx below the vocal cords. In 
one of my cases of this sort, the evulsion was incomplete, 5 but in two 
others the tumor was entirely eradicated. When a growth, however, is 
situated in the ventricle, and only slightly projects from the ventricular 
orifice, it is sometimes impossible to remove it entirely from above. The 
projecting portion may be cut off, but the base remains. 

The occurrence of inflammation or spasm of the glottis, on attempted 
laryngoscopic treatment, may render the combined method necessary 
(tracheotomy having first been performed, and evulsion being subse- 
quently effected through the fauces), but it does not in itself justify an 
extra-laryngeal operation for evulsion. 

An insuperable irritability of the fauces, or an extremely nervous con- 
dition of the patient, may, however, render laryngoscopic treatment impos- 
sible; and in these cases an extra-laryngeal treatment may be necessary. 
In the case of young children who cannot be taught to submit to laryn- 
goscopic treatment, extra-laryngeal treatment may be required ; but it 
must not be forgotten that very young children have been successfully 
treated with the aid of the laryngeal mirror. 

1 Mackenzie: Ibid., Appendix A, Case 3. -Op. cit. 3 Op. cit. 

4 Mackenzie: Op. cit., Appendices A and C, Cases 3, 52, 92, 95, etc. 

5 Ibid., Appendices A and C, Case 24. 



236 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

Contra- Indications for extra- Laryngeal Methods. — It may be stated 
as a cardinal law, that an extra-laryngeal method ought never to be adopted 
'.(even where laryngoscopic treatment cannot be pursued) unless there be 
danger to life from suffocation or dysphagia. Direct incision into any 
part of the air-passages is always attended with both immediate and re- 
mote danger to life, the amount of risk, however, not being great, as a rule. 
Dysphonia does not justify operations, which, though easy to perform, may 
be regarded as " capital." Hence an extra-laryngeal operation is not justi- 
fiable for the removal of a small growth in the larynx, unless that growth 
give rise to dangerous dyspnoea, and cannot be removed by a less serious 
method. 

Contra-indications based on danger to life, having been thus briefly 
pointed out, it only remains for me to remark that destruction of the vocal 
function is often the result of any extra-laryngeal method. 

Extra-laryngeal methods of extirpation may be carried out in one of 
three ways: 1st, By division of the thyroid cartilage, or thyrotomy; 2dly, 
by supra-thyroid laryngotomy, or division of the thyro-hyoid membrane; 
and 3dly, by infra-thyroid laryngotomy (through the crico-thyroid mem- 
brane), or tracheotomy. 

Division of the Thyroid Cartilage, or Thyrotomy — History. — This 
important operation was first proposed for the removal of laryngeal 
growths by Desault, at the end of the eighteenth century. His remarks, 
which were perfectly true before the invention of the laryngoscope, are 
as follows: " In cases of polypi of the larynx, the indications are twofold; 
viz., the extirpation, or ligature of the growth, and the re-establishment 
of a passage for air; and they both necessitate laryngotomy. It rarely 
happens, indeed, that laryngeal excrescences project so far into the mouth, 
that they can be seized and extirpated or ligatured per vias naturales" l 
The operation was not, however, carried out till the year 1833, when it 
was performed for the first time by Brauers of Louvain. Ten years later 
it was repeated by Ehrmann of Strasbourg. In 1851 it was practised by 
Gurdon Buck, and again by the same surgeon in the year 1861. The in- 
vention of the laryngoscope naturally gave an impetus to this operation. 

Indications for Operation. — This operation may be required for the 
removal of large growths in the cavity of the larynx, which cause great 
dyspnoea or dysphagia, and cannot be removed with the aid of the laryngo- 
scope; or for the evulsion of growths in the subglottic region, which can- 
not be extirpated by indirect laryngotomy (through the crico-thyroid 
membrane). It might be thought that this operation would be called for 
in the case of children; but the facility with which even very young chil- 
dren can be treated laryngoscopically has already been pointed out; and it 
must not be forgotten that when the larynx is small, thyrotomy is much 
more likely to lead to injury of the vocal cords. 

Dr. Paul Bruns has successfully refuted the assertion that either the 
very large size, extremely hard consistence, unusually broad insertion, un- 
favorable situation, or multiplicity of the neoplasms, is, a priori, sufficient 
to contra-indicate a trial of the endo-laryngeal method. " It is only in 
certain rare exceptional cases," Paul Bruns observes, " in which several 
of these unfavorable conditions occur together, that we are entitled, a pri- 
ori, to consider the attempt at removal per vias naturales as having no 
favorable prospect, e. g., in some cases of solid tumors with very broad 

1 This quotation is taken from a later edition of Desault's (Euvres chirurgicales, by 
Bichat, Paris, 1812, vol. ii. p. 255. 



NON-MALIGNANT TUMORS OF THE LARYNX. 23 f 

bases situated below the glottis or originating in the ventricles." Here 
he shows, that out of 1,100 neoplasms, there were 602 papillomata, and 
346 fibromata (constituting together 86 per cent, of all these growths) ; 
further, that 836 out of these growths originated from the vocal cords, 
while only three-fifths per cent, were situated below the glottis or in the 
ventricles. Consequently it is proved that three-fourths of all laryngeal 
growths are of such a nature and so situated, that they are well suited for 
endo-laryngeal interference. Whilst proving further by a good many ex- 
amples, that growths springing from the under surface of the vocal cords, 
and those originating within the ventricles, have been and may easily be 
extirpated through the mouth if they are pedunculated, he, nevertheless, 
admits that sicbc or dal or ventricular neoplasms, which have no pedicle, or 
are seated on a very broad base, or show an inclination to recurrence, be- 
long to the department of laryngotomy. For the removal of subcordal 
growths, however, he recommends partial laryngotomy (cricotomy or crico- 
tracheotomy with preservation of the thyroid cartilage), and only sanc- 
tions thyrotomy for the extirpation of tumors originating within the ven- 
tricles. 

Jfethod of Procedure. — The first question which arises is whether tra- 
cheotomy should or should not be performed as a preliminary measure of 
safety. I agree with Paul Bruns, " that previous or simultaneous trache- 
otomy, although it has been performed in by far the greater majority of the 
cases, is not required by the nature of the operation, unless there be other 
conditions necessitating its performance, such as dyspnoea." If trache- 
otomy is first performed, thyrotomy should not be at once carried out, but 
endo-laryngeal treatment should be carefully attempted when the tracheal 
canula has been worn for a few weeks. This failing, the surgeon may 
have recourse to the more severe treatment. 

The incision for thyrotomy should be made exactly in the median line, 
through the textures over the thyroid cartilage, from the thyroid notch 
to the upper border of the cricoid cartilage. The thyroid cartilage 
should then be most carefully divided by a succession of small nicks, with 
a short, strong, sharp-pointed knife ; but if ossification has taken place, 
the opening must be effected with a small circular or convex saw. If 
possible, the upper extremity of the projecting angle of the thyroid car- 
tilage (pomum Adami) should be left intact, as the complete division of 
the cartilage in this situation is likely to be followed by changes in the 
relations of the vocal cords to one another, resulting in permanent apho- 
nia. The instrument should not be allowed to penetrate the larynx 
until the whole of the cartilage is divided. 1 By this method the parox- 
ysms of coughing, which otherwise interfere with the operation, are often 
avoided. When divided, the alae of the cartilage should be kept widely 
apart by means of strong retractors held by two assistants, one on each 
side of the patient. The retractors should be like miniature pitch-forks, 
with the points blunted and bent round, so that they can hold back the 
alae. 

If the alae cannot be thrown back, the crico-thyroid membrane should 
be divided along the lower edge of the thyroid cartilage, on one side, or, 
if necessary, on both sides. If there be still insufficient room, the thyro- 
hyoid membrane should be divided, by a horizontal incision along the 
upper edge of the thyroid cartilage. Horizontal division of the mem- 



1 This precaution is justly insisted on by Krishaber and Planchon (Faits cliniques 
de Laryngotomie, Paris, 1809, p. 93). 



238 DISEASES OF THE PHAKYNX, LARYNX, AND TRACHEA. 

branes, however, is not generally necessary, and the thyro-hyoid should 
if possible be left intact. 

The operator should now throw a strong reflected light into the open- 
ing, and, guided by it, and his previous laryngoscopic knowledge of the 
case, he will be able to seize the growth with a hook or forceps, and di- 
vide it with a pair of short-curved scissors. On account of the small 
space at the command of the operator, the growth may sometimes be cut 
through with a knife, without being previously seized, or it may be torn 
away with forceps. Sometimes, however, even after total division of the 
thyroid cartilage, the extensive attachments or dense consistence of the 
growth prevents its removal, 1 and the surgeon is obliged to desist from 
the operation. If all goes well, after the growth has been excised, its 
base should be firmly touched with solid nitrate of silver. Actual cautery, 
acid nitrate of mercury, and galvanic cautery, have all been used, but I 
prefer the nitrate of silver, as less likely to give rise to laryngitis, and 
quite as effectual when applied to a raw surface. 

The two aire of the thyroid cartilage should then be carefully brought 
together, in their exact normal situation, with two silver sutures, and the 
edges of the wound united with plaster. The canula should be allowed 
to remain in the trachea, for, at least, a few days, until all danger has 
passed off; or if there be any likelihood of recurrence, till further steps 
have been taken to effect complete eradication. 

In some cases the cricoid cartilage has been divided, and though no 
harm appears to have resulted from its section, it is better, if possible, to 
leave it intact. Krishaber 2 justly remarks that division of the cricoid 
•cartilage is altogether unnecessary; for whilst, on the one hand, it does 
not facilitate the removal of growths above the vocal cords, those below 
the glottis can easily be removed through an opening either in the crico- 
thyroid membrane or in the trachea. 

Comparative Merits of Thyrotomy. — Unlike the operation conducted 
per vias naturales, the procedure now under consideratien is a very serious 
one, both as regards the danger to life and the risk of destruction of 
function. 

In 1873 3 I published some articles on the results of thyrotomy, based 
on forty-eight cases, which comprised all then published. The following 
is a brief summary reduced to percentages, and placed in a tabular form: 

Per cent, on 48 cases. 

Complete success 4 14.58 

Partial success 22.91 

Death 8.33 

Severe dyspnoea requiring use of canula 31.25 

Severe dyspnoea requiring fresh operation 8.33 

I have also tabulated the following other results, which are based on 
thirty-nine cases of benign growth, in which, the voice being affected 
before the operation, the patient survived more than a few days : 



1 Paul Brans: Op. cit., p. 167. 

2 Op. cit. 

3 Brit. Med. Joura., May, 1873. 

4 Complete success is understood by me to mean recovery of perfect voice and per- 
fect respiration, and absence of recurrence of growth ; partial success to mean recov- 
ery of one function with injury to another, or temporary recovery of both functions, 
•but subsequent recurrence of the growth. 



NON-MALIGNANT TUMOKS OF THE LARYNX. 239 

Aphonia 40.0 per cent. 

Dysphoria 20.0 

Modified voice 11.11 

Not stated, but probably defective voice. . . 6.Q6 a 
Recurrence, or incomplete removal 38.46 " 

The following are some of the conclusions which I arrived at: 

(a.) That the operation ought never to be performed for loss of voice 
alone. 

(b.) That the operation should be confined to those cases in which 
there is danger to life from suffocation or dysphagia, and even then 
should only be performed after an experienced laryngoscopist has pro- 
nounced it impossible to remove the growth joe?' vias naturales. Dr. Paul 
Bruns ' in his valuable work on the relative merits of thyrotomy and endo- 
laryngeal operations for the removal of growths, remarks: " I quite agree 
with Mackenzie that ' laryngotomy is only justifiable when an experienced 
laryngoscopist has declared the removal of the growth per vias naturales 
impossible ' (Brit. Med. Jour., May 3, 1873, p. 488) — ' only, I should say, 
after he (an experienced laryngologist) has attempted the removal in 
vain. 9 " 

In order to thoroughly weigh the merits of thyrotomy, it is necessary 
to consider the prospects of the operation: (1), in relation to the preser- 
vation of life; (2), in relation to the recovery of voice; and (3), in rela- 
tion to the immunity from recurrence. Each of these points will now be 
discussed in detail. 

(1.) In Relation to Life. — In division of the laryngeal cartilages there 
is always some immediate danger. One patient died from secondary 
hemorrhage a few days after the operation, and several others have rap- 
idly succumbed to pleurisy, pneumonia, or metastatic abscess of the lungs. 
In Dr. Cutter's case the patient w T as almost suffocated during the opera- 
tion; and in one of Navratil's earlier cases, the hemorrhage was alarming, 
and the patient nearly died from the quantity of blood which passed down 
the trachea. In another of that surgeon's cases the patient suffered from 
high fever, and expectorated a quantity of blood and pus: oedema took 
place round the wound, and the patient was in a very critical state. 

The usual risks attending the ordinary operations for opening the air- 
passages, are also, of course, present, and tracheitis or bronchitis may 
supervene. In addition to the immediate danger, there is also the con- 
tingent risk of chronic perichondritis at a later period. 

(2.) In Relation to Voice. — In discussing this question, Bruns shows 
that the operation is very fatal to the vocal function. He takes excep- 
tion to my statistics 2 on the ground that I have estimated the functional 
result together with that of the operation, in a general way, without stat- 
ing whether the whole growth was removed, or whether recurrence took 
place or not — a method which naturally yields untrustworthy results. 
Bruns, therefore, carefully excludes from his statistics all those cases of 
final alteration or loss of voice in which this change could possibly be at- 
tributed to any other cause than the operation itself. Thus, out of the 
ninety-seven cases on record, thirty-eight only can be used for the de- 
cision of the question, whether the operation is, in itself, dangerous to 
the vocal function. Of the reality of this danger there can, however, be 
no doubt, for in 47 per cent, only (eighteen cases) out of these thirty-eight 

1 Op. cit. 3 British Medical Journal, 1873, p. 488. 



240 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

cases, was a normal or nearly normal voice restored or retained, while in 
twenty cases, the voice was either completely lost (six cases), or reduced 
to nearly complete aphonia or extreme hoarseness (fourteen cases). We 
see, therefore, that, in the majority of cases, the operation itself brings 
the vocal function into great danger. 

(3.) In Relation to Recurrence of Growth. — It might be expected that 
extirpation could be more completely effected when the thyroid cartilage 
is divided, and the larynx thoroughly exposed to view, and that thus 
recurrence would be less frequent; but this supposition is not borne out 
by facts. 

Dr. Paul Bruns has well pointed out, that the question of recurrence 
must be decided upon an examination of the cases of papilloma only; for 
fibromata do not recur, and the number of sarcomata operated on hitherto, 
is too small to permit of any satisfactory conclusion. Further, only those 
cases can be made use of which were under observation for a considerable 
time after the operation. Of Dr. Bruns's cases, one was only observed 
for five weeks, but most of them were kept in view for many months and 
even years. Distinctions of age must also be taken into account, chil- 
dren being separated for comparison from adults. 

In the case of children Bruns ' has collected seventeen instances of 
thyrotomy. Of these there were eight cures and nine recurrences. Out 
of forty cases treated by the endo-laryngeal method, twenty-six only 
were available. Among these we find thirteen cures and thirteen recur- 
rences, but the latter number includes seven cases in which the growth 
had not been entirely removed, and which therefore do not properly be- 
long to the category of recurrence. It must be admitted, however, that 
the cases of thyrotomy had a priori worse prospects than the others, the 
operation having been performed almost without exception in cases of 
multiple papilloma, and in the overwhelming majority of cases on chil- 
dren under ten years, while these unfavorable conditions were both present 
in only one-half of the cases treated per vias naturales. 

In adults there were twenty-two cases of thyrotomy, with ten cures 
and twelve recurrences. Seventeen were cases of multiple, and five of 
solitary, papilloma. In the latter class recurrence took place only once, 
but in the former eleven times. With regard to the endo-laryngeal opera- 
tion, on the other hand, after taking the above-mentioned precautions, 
there are only sixty-four cases, out of the great number on record, which 
can be used for these statistics. These sixty-four cases show forty-seven 
cures and seventeen recurrences. In thirty-one cases the papilloma was 
solitary (twenty-four cures and seven recurrences); in thirty-three multi- 
ple and diffuse (twenty-three cures and ten recurrences). Six of these 
cases were only cured after repeated operations. 

These statistical tables show, therefore, that the frequency of recur- 
rence after either method in adults and children together is as follows: 
(1.) Thyrotomy, thirty-nine cases, eighteen cures, twenty-one recurrences; 
(2.) Endo-laryngeal method, ninety cases, sixty cures, thirty recurrences, 
or, in other words, whilst thyrotomy gives a few more recurrences than 
cures, the endo-laryngeal method shows twice as many cures as recurrences. 
These numbers thoroughly refute the unfounded assertions of the parti- 
sans of thyrotomy. 



Op. cit., p. 147 et seq. 



NON-MALIGNANT TUMORS OF THE LARYNX. 241 

The following is an abstract of Paul Bruns's conclusions on the more 
important matters: 

(A.) Thyrotomy is not dangerous to life, nor difficult to perform, but 
it is, in itself, very dangerous to the vocal function. The pretended ad- 
vantages as to the facility of its performance, the certainty of complete 
extirpation, and the security against recurrence, do not exist in reality. 

(B.) Thyrotomy can therefore in no wise be placed on a par with the 
endo-laryngeal method, and is to be performed only if an experienced la- 
rvnoroscopist has unsuccessfully attempted the endo-laryngeal operation. 

(C) Even in this case thyrotomy should not be performed if it can 
possibly be avoided, but partial laryngotomy (division of the crico-thyroid 
ligament, and, if necessary, of the cricoid cartilage and the superior tra- 
cheal rings), inasmuch as everything depends (so far as the restoration of 
function is concerned) on the question, whether the operation can be per- 
formed without the division of the thyroid cartilage (i. e., the anterior 
commissure of the vocal cords). 

(D.) In urgent cases, in which tracheotomy has to be performed for 
the relief of dyspnoea, thyrotomy should never be undertaken until re- 
moval by the endo-laryngeal method has been first attempted; and in 
these cases success may often be obtained by " partial " laryngotomy, the 
tracheal incision being prolonged through the cricoid cartilage. 

(E.) If after endo-laryngeal removal of papillomata recurrence takes 
place, the same method ought to be tried over and over again, as there 
are many cases on record, showing that after frequently repeated opera- 
tions complete cure was finally obtained. 

On the subject of thyrotomy Dr. Fauvel l remarks, " I am extremely 
astonished to see surgeons, and still more so specialists in laryngoscopy, 
when they have only to deal with a simple polypus not menacing the 
life of the patient, still having recourse to this barbarous method, which 
consists in making an opening in the neck for extracting, by this danger- 
ous, and often, too narrow way, tumors of a greater or less volume and 
consistence. The laryngoscope shows the polyp as plainly as possible; 
and also its seat, form, and size. It is therefore useless, not to speak 
more strongly, to establish, at the cost of a severe and bloody operation, 
an artificial opening into the larynx. This opening has no other result, 
I repeat, than to expose the polyp and permit an operation — two con- 
ditions which are completely fulfilled by the laryngoscope." He further 
proceeds to point out the danger of the operation from hemorrhage, and 
remarks that " in one case of thyrotomy, he icas obliged to apply thirty- 
eight ligatures, though tracheotomy had been performed a month previ- 
ously, and the patient wore the canula during the time the thyrotomy 
was being undertaken." 

Removal of Groicths by Division of the Thyro-Hyoid Membrane, or 
Supra- Thyroid Laryngotomy. — This method of treatment is indicated 
for the removal of large growths situated at the upper orifice of the la- 
rynx, which cannot be taken awayjper mas naturales. 

The operation, originally proposed at about the same time by Mal- 
gaigne* and by Vidal de Cassis, 3 was first carried out in the year 1859. 



1 Op. cit. pp. 227 and 229. 

'-' The claim to originality is made by Malgaigne in his Manuel de Medecine opera- 
toire, Paris, 1871, 7me edition, p. 525. 
:1 Velpeau : Medecine operat. 
1G 



2-12 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

The operator was Dr. Prat, a surgeon in the French navy, stationed at 
that time at Papiete, the capital of Otaheite. The patient, who was the 
subject of advanced pulmonary phthisis, suffered also from such extreme 
difficulty of swallowing, that he could scarcely take any food. The dys- 
phagia was due to a growth, which appears to have been situated on the 
under-surface of the epiglottis; it could be felt with the finger, but all 
attempts to seize and remove it through the mouth entirely failed. Bv 
operating after the manner recommended by Malgaigne, Dr. Prat easily 
removed the growth, which was of a compact fibrous structure and grayish 
white color. Xo vessels were tied. The wound healed quickly, and the 
symptoms from which the patient had suffered disappeared. He died 
shortly afterward from phthisis, and at the autopsy no trace of the growth 
was to be found. 1 In the year 1863 Follin 2 performed a similar operation 
with complete success. The neoplasms were extirpated, and the patient 
was entirely cured. 

Transverse incision through the thyro-hyoid membrane should, accord- 
ing to Malgaigne,. be made along the lower border of, and parallel with, 
the hyoid bone, through the skin, superficial fascia, the inner half of the 
sterno-hyoid muscles, the thyro-hyoid membrane, and the mucous mem- 
brane which extends between the base of the tongue and the epiglottis, 
and forms the glosso-epiglottic ligament. The side of the epiglottis 
should then be seized and drawn through the wound. The growth can 
then be removed, according to the circumstances of the case, by bistoury, 
scissors, or forceps. It may be stated that Follin divided the thyro-hyoid 
membrane along the upper border of the thyroid cartilage, that is, rather 
lower down than advised by Malgaigne, with a view of avoiding the epi- 
glottis; and as far as I can gather from the report of his case, the incision 
was carried further outward than in Prat's case. The latter procedure 
certainly renders the epiglottis less likely to be wounded, but little im- 
munity is afforded to the valve by making the incision a few centimetres 
lower down than recommended by Malgaigne. It must also be remem- 
bered that the more external the incision is carried, the greater is the 
danger of wounding important vessels. In any case, the hyoid branch of 
the thyroid artery is not unlikely to be wounded, but this is not a matter 
of any importance. 

Although subhyoid laryngotomy is unattended with any considerable 
danger, either immediate or remote, I do not think that it will find much 
favor with those skilled in operating with the aid of the laryngeal mirror; 
for it happens that those cases which are favorable to the performance of 
this operation are just those which, as a rule, can be most easily treated 
through the mouth. 

The operation is much less serious than thyrotomy, in relation to life, 
and is not attended with any risk to the vocal function. In operations 
involving the cartilages which form the framework of the larynx, there 
is, as has been already pointed out, always the danger of subsequent 
caries; but it is well known that injury of the elastic cartilages, though 
it may cause temporary inconvenience, is unattended with permanent 
risk. Not only do we frequently find that patients, recovered from ter- 
tiary syphilis, with the mere stump of an epiglottis, can swallow perfectly 
well; but it has already been proved, in the celebrated case of Prince 



1 Gazette des Hopitaux, 1859, No. 103, p. 809. 
- Archives Generates de Medecine, Fevrier, 1867. 



NON-MALIGNANT TUMORS OF THE LARYNX. 243 

Murat, 1 that the epiglottis may be suddenly cut away with only temporary 
inconvenience. Again, most hospital surgeons must have frequently met 
with extensive suicidal wounds of the thyro-hyoid membrane involving the 
epiglottis, which have healed rapidly without any bad results. This last 
fact has been illustrated by some remarkable cases by Kunst. s 

Removal of Growths by Infra- Thyroid Lary myotomy {through the 
Crico- Thyroid Membrane), or by Tracheotomy. — This mode of eradicating 
growths was recommended by Professor Czermak in the year 18G3; but 
it was first successfully employed two years later by Dr. Burow, senior, 3 
of Koenigsberg. In the year 18G9 it was carried out, for the second time, 
by myself. 4 Since then eleven other cases have been placed on record, 
all of which are briefly detailed in Paul Bruns's work. The operation is 
recommended for the removal of laryngeal growths situated in the sub- 
glottic region, as well as for tumors in the upper part of the trachea, 
when, in such cases, laryngoscopic treatment cannot be carried out. Paul 
Bruns strongly recommends this operation for the extirpation of tumors 
originating from the free borders and the lower surface of the vocal cords 
or from below the glottis. If they are small and pedunculated, the crico- 
thyroid membrane alone, or the cricoid cartilage in addition, may be 
divided, but only if previous endo-laryngeal attempts at removal have 
been unsuccessful; if the growths are large, and attached by abroad base, 
laryngo-tracheotomy should be adopted, without any endo-laryngeal at- 
tempts, as by this operation alone a thorough cure can be expected. 

A few days before evulsion is attempted, an incision should be made 
as in ordinary (crico-thyroid) laryngotomy, but the crico-thyroid opening 
should be carefully dissected out, and all the membrane, muscle, and su- 
perficial parts removed, so that nothing is left but the two cartilages sur- 
rounding the opening; a canula should then be inserted. When all dis- 
position to hemorrhagic oozing has ceased, and all tenderness disappeared, 
the canula should be taken out, the chin thrown well back, so as to enlarge 
the crico-thyroid space as much as possible, and a careful examination 
made with one of Xeudorfer's infra-glottic mirrors, to ascertain the exact 
origin of the growth. The mirror must then be laid aside, and the growth 
removed with short tube-forceps. 

This operation can only be performed where the crico-thyroid mem- 
brane is of average size; if there is not room to effect removal, tracheotomy 
should be performed in the first instance instead of laryngotomy. The 
steps of the operation are almost the same as in (crico-thyroid) laryngot- 
omy. When the patient has recovered from the tracheotomy, that is to 
say, a few days after the operation, the canula should be removed, and an 
attempt made to extirpate the growth. In carrying out the operation, 
the two sides of the windpipe require to be held back with retractors, in 
order that instruments may be conveniently passed into the larynx. 

The patient should continue to wear the canula for a few months, or, 
at any rate, for a few weeks, in case eradication be incomplete, or recur- 
rence take place. 



1 In this historical case, which occurred at the battle of Aboukir, half of the epi- 
glottis was carried away by a musket-ball. Under Baron Larrey's treatment the patient 
recovered. Another similar case occurred in the same campaign, with an equally for- 
tunate result. (Larrey: C'linique chirurg., t. ii. p. 142; Relation chirurg. de l'Armue 
d'Orient, p. 280. quoted by Ryland. ) 

2 Eroff. der oberst. Lut'twege, Leipzig, 1864, p. 45. 

3 Deutsche Klinik, vol. xvii. p. 165. 

4 Op. cit., Ca=e 81. 



244 DISEASES OF THE PHARYNX, LAKl'NX, AND TKACHEA. 

[MALIGNANT TUMORS OF THE LARYNX. 

Under this head are included (1) Carcinomata, and (2) Sarcomata.] 

CANCER OF THE LARYNX. 

Latin Eq. — Carcinoma laryngis. 
French Eq. — Cancer du larynx. 
German Eq. — Krebs des Kehlkopfs. 
Italian Eq. — Cancro della laringe. 

Definition. — Primary cancer of the larynx, giving rise to hoarseness, 
dyspnoea, pain in the throat (darting to the ears), sometimes to dysphagia, 
and ultimately causing death either by marasmus, or, if tracheotomy has 
not been performed, by apnoea. 

Etiology. — The cause of cancer of the larynx, as of malignant disease 
in general, has not yet been discovered. With respect to age, like the 
same disease in other parts, it is more frequent in advanced periods of 
life. The following table of 53 cases occurring in my practice illustrates 
this point. It will be seen that nearly the whole of the mortality (i. e., 
83 per cent.) takes place between the ages of forty and seventy. 



From 10 to 20 years of age 1 



20 to 30 
30 to 40 
40 to 50 
50 to 60 
60 to 70 
70 to 80 



2 

6 

10 

18 

15 

1 



Ziemssen ' publishes a table of 76 cases, collected from various authors, 
which gives very similar results, but includes 3 cases under nine years of 
age and 3 between the ages of ten and nineteen. 

As regards sex, 42 of my cases were men and 11 women, whilst of 
Ziemssen's 76 collected cases 60 were males and 16 females. In 44 cases 
of laryngeal cancer observed by Fauvel, 2 the relative distribution with re- 
spect to age and sex is almost identical. 

Symptoms. — The subjective symptoms of cancer of the larynx are not 
of a very distinctive character. Pain, dyspnoea, and dysphagia are gen- 
erally present, but these symptoms vary according to the stage and exact 
site of the disease. My experience accords with Fauvel, 3 who states that 
at first the pain is confined to the larynx, and that not until ulceration 
has commenced does it radiate to the ears, orbit, and forehead. Pain is 
sometimes felt in the submaxillary and cervical glands, but this is com- 
paratively rare. 



1 Cyclopaedia of Medicine, vol. vii. p. 891. 

- Traite pratique des Maladies du Larynx, Paris, 1876, p. 683 et seq. 

3 llr.d. p. 707. 



CANCER OF THE LARYNX. 245 

Objectively, the groups of symptoms presented by laryngeal cancer 
are striking, and almost always sufficiently characteristic to enable the 
observer to arrive at a definite opinion as soon as the disease has begun 
to develop organic changes. Hoarseness, sometimes due to implication 
of the recurrent nerve, is a very early symptom, and sometimes precedes 
all other symptoms by months or even years. The disturbance of phona- 
tion is of course progressive, but, as Dr. Fauvel has pointed out, the 
voice is seldom entirely lost, as it is in laryngeal phthisis, and by an effort 
the patient can generally succeed in producing a vocal sound. As soon 
as ulceration takes place there is fetor of the breath, and this is in itself 
a strong indication of the nature of the malady. As ulceration advances 
another symptom — hemorrhage, which when serious is almost pathogno- 
monic of cancer — may be met with. There may be copious bleeding 
from one or more small vessels being laid open, or the bloody discharge 
may only be sufficient to tinge the expectoration, which in almost all 
cases consists of ichorous muco-pus. 

The external condition of the neck seldom affords any evidence as re- 
gards laryngeal cancer. Occasionally, however, at an advanced stage of 
the disease, the submaxillary glands are enlarged, and in some rare cases, 
owing to intra-larvngeal tumefaction, the alae of the thvroid cartilag-e are 

O */ O ' o 

pressed outward, so that, as Isambert ! has pointed out, the cartilage feels 
very much like a " crustacean carapace." More rarely still, the caflcer eats 
through the integument. 

As regards the general condition of the patient in laryngeal cancer, 
the essential cachexia does not present itself so uniformly as in malignant 
disease of other parts. This can readily be explained by the fact that the 





Fig. 61.— Epithelioma of the Left Ven- Fig. 62.— Epitheliomatous Ulcer- 

tricmar Band. ation of the Right Ary-epiglottic Fold 

and Thickening of the Epiglottis. 

connection of the lymphatics with the glandular system is not nearly so 
free as in the pharynx and other parts (see page 155). Where, however, 
life is much prolonged, as in those cases in which swallowing is little in- 
terfered with, and tracheotomy has been performed at an early period, 
the characteristic cachexia is sometimes present. 1 only know of one in- 
stance in which cancer has developed secondarily in other parts of the 
body — the original disease having been in the larynx. 

The laryngoscopic appearances vary according to the stage of the dis- 
ease. At first the neoplasm appears as an undefined swelling, without 
any features which clearly indicate its nature. The site of the tumor is 
in most cases one of the ventricular bands (Fig. Gl), but in some instances 
one of the vocal cords, the epiglottis, or the ary-epiglottic folds, have 
been the first part to be attacked. Any part of the larynx may, hoVever, 



1 Annales d. Malad. de l'Oreille et du Larynx. T. ii. p. 8. 



246 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

suffer from the encroachment of the morbid growth, so that after a time 
it becomes impossible to decide at what point it commenced (Fig. 02). 
Sometimes the growth covers the entire larynx, as in certain cases of 
diffuse epithelioma (Fig. G3). 

When the disease attacks the epiglottis it often causes so much gen- 
eral swelling, that the interior of the larynx cannot be seen; but occa- 




Fig. 63.— Diffuse Epithelioma. 




Fig. 64. — Epithelioma of the 
Epiglottis. 



sionally it slowly eats away the cartilage without causing any tumefac- 
tion. This is well shown in a case exhibited by me some years ago at 
the Pathological Society (Fig. 04). 

The following table shows the site of the disease in my 53 cases of 
primary laryngeal cancer, when the patients first presented themselves, or 
when the disease became manifest: 



Times. 

The right ventricular band 15 

The left ventricular band . 13 

The left vocal cord 3 

The left vocal cord and subglottic region 2 

The right vocal cord 2 

The anterior commissure of the voc;:i t ords 2 

The epiglottis 6 

The posterior surface of the cricoid cartilage 1 

The whole of larynx 9 

It will be seen that in 50. 7 per cent, of cases, one of the ventricular bands 
was the part first affected. 

Both Fauvel ' and Ziemssen 2 illustrate the question as to the site of 
cancer of the larynx by reference to their cases. Thus in 37 cases ob- 
served by the former physician, 20 occurred on the left side, and of these 
the ventricular band was first affected in 10. Ziemssen thinks that the 
vocal cords or the ventricles of Morgagni are the usual points from which 
the growth spreads upward to the ventricular bands and ary-epiglottic 
folds. 

In the encephaloid variety of the disease the tumor appears in single 
nodules and ulcerates early. As soon as ulceration is established a pro- 
cess of sprouting commences, and as Fauvel has well pointed out, the 
vegetations issue from the ulcerated surface, and do not attack the sur- 
rounding mucous membrane, which remains more or less intact for some 



Op. cit. p. C93. 



2 Op. cit. p. 891. 



CANCER OF THE LARYNX. 247 

time, being but slowly eaten away by the gradual spreading of the pri- 
mary ulcer. On the other hand, in epithelioma, as soon as an ulcer has 
formed, a series of vegetations spring up about its margins, and these 
new growths, by ulcerating in their turn, rapidly increase the original 
loss of substance. In scirrhus the disease in the earliest stage has much 
the appearance of a benign growth — a smooth papilloma or fibroma — but 
the surface of the growth and the neighboring mucous membrane soon 
become inflamed, and in a short time distortion of some part of the larynx 
may be observed. From the foregoing remarks it will be understood 
that the laryngoscopic picture of a fully developed case of ordinary la- 
ryngeal cancer is that of a neoplasm, variable in size, single or multiple, 
whose surface is in a state of fungous ulceration, and frequently bathed in 
a purulent secretion or a sanguineous muco-pus. 

In the only case of adenoid cancer that I have met with (Fig. 65), the 
disease commenced with ulceration of the epiglottis, and from this spot a 
nodulated growth about the size of a cherry developed. 

Pathology. — Epithelioma is by far the most common form of cancer 
which affects the larynx. Out of my 53 cases, 1 45 were epitheliomatous (one 
of these adenoid), 2 scirrhous, and 6 encephaloid. In (38 cases collected 
by Ziemssen, 57 were examples of epithelioma, 
9 encephaloid or scirrhous, and 2 villous. Fau- .. ' ; | 

vel, 2 however, in 39 cases met with different / ^' ^ 

results, there having been 19 examples of ence- ^j-^'^msM^ 
p haloid disease, 16 of epithelioma, and 2 doubt- 
ful cases. Schroetter 3 has reported twenty cases 
of cancer, 17 of which were examples of epithe- 
lioma, and 3 of encephaloid. In 10 out of 32 
cases on which I made a post-mortem, the car- 
tilages were necrosed ; but I believe that these fig. 65.— Adenoid Cancer, 
structures are affected in a much larger pro- 
portion of cases than these figures indicate. The condition of the carti- 
lages cannot, however, be ascertained without destroying the specimen for 
museum-purposes, and this consideration has unfortunately prevented me 
from satisfactorily arriving at any conclusion on the subject. There was 
some oedema in every fatal case, as well as in 11 out of 21 cases seen only 
during life. 

Diagnosis. — In the early stages of laryngeal cancer the diagnosis is 
often doubtful, but as soon as a tumor is formed, the experienced laryn- 
gologist can nearly always roughly determine its character. The appear- 
ance of a considerable but irregular and undefined swelling of a dirty 
gray or bright red color on one of the ventricular bands, in a patient past 
the middle period of life, without any histor} T of syphilis or previous severe 
chronic laryngitis, should raise grave suspicions of malignant disease. 



1 In only 27 of the cases of epithelioma, and in only 3 of the cases of encephaloid 
disease, was the disease verified by post-mortem examinations. In both the cases of 
scirrhus the diagnosis was confirmed by microscopical examination. The paucity of 
autopsies is to be explained by the fact that we often lose sight of our cancerous 
patients as the fatal issue approaches. On this subject. Isambert, (Op. cit. p. 3) ju- 
diciously remarks : " Hospital patients suffering from cancer are not like the tubercu- 
lous ; the former make no mistake as to their prospects, and disappear from our no- 
tice to die in their own homes." Thus it happens that we are so often deprived of 
the means of verifying our diagnosis. 

'-' Op. cit. p. 689. 

3 Laryngol. Mittheilungen, Wien, 1875, pp. 65 and 70. 




248 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

Similar conditions in other parts of the larynx will likewise call for close 
observation. As soon as the tumor ulcerates, the fungous character of the 
sore is usually very characteristic, but nevertheless in no case should the 
patient be condemned as suffering from cancer until all doubts have been 
cleared up by the trial of antisyphilitic treatment. 

Prognosis. — As far as the present state of our knowledge extends, the 
only possible termination of any case of cancer is death, but at the same 
time the question must always arise as to how long life may last in any par- 
ticular instance. The usual duration of epithelioma of the larynx appears 
to be about eighteen months, and of encephaloid three years; in the cases 
which have been reported as lasting for ten or fifteen years, 1 1 cannot ima- 
gine that the disease was malignant from the commencement. On the other 
hand, patients often perish in a few months through some untoward 
event, such as acute oedema, perforation into the oesophagus, or lung com- 
plications. 

Treatment. — Endolaryngeal treatment, thyrotomy, extirpation of the 
larynx, and tracheotomy are the various procedures which must be con- 
sidered. 

As regards endolaryngeal treatment, it need only be remarked that 
the radical removal of an ill-defined tumor cannot be efficiently accom- 
plished by this method. 

The results of thyrotomy have been shown by Dr. Paul Bruns 2 to be 
as follows : 

In twenty cases in which thyrotomy was performed for the removal of 
malignant growths (most of which were epitheliomata), death ensued after 
a few days in 2 cases. In the remaining 18 3 cases there was immediate 
recurrence in 4 cases, and recurrence a fortnight after the wound had 
healed in four cases ; there was recurrence after from two to four months 
in 3 cases, after from five to six months in 2 cases, and within eighteen 
months in one case ; the result was not reported in 3 cases. In the remain- 
ing single case no recurrence followed for a considerable time. It is true 
that death occurred twenty-two months after the operation from carci- 
noma of the left kidney and left suprarenal body, but there w T as no trace 
of recurrence in the larynx. The functional result was unfavorable in all 
these cases. It will thus be seen that the results of thyrotomy are ex- 
tremely unsatisfactory. In some cases the operation was followed by im- 
mediate death, in others it could not be completed, and in the remaining 
cases, with two exceptions only, recurrence followed within a very short 
time. If the few statistics which have been collected are to be trusted, 
the average duration of life after the operation is only ten months. The 
mode of performing thyrotomy has already been explained (see page 
237), but it may be remarked here that, in order to obtain any chance of 
success by this operation, every particle of the morbid growth must be 
excised, and the resulting wound well cauterized with nitrate of silver, or 
even by the actual cautery. 

According to Fauvel, 4 tracheotomy always adds several months and 
often even a year or two to the patient's existence. Thus in 7 cases of en- 
cephaloid left to their own course, the average duration of life was three 



1 See Ziemssen's table : Op. cit. p. 899. 

2 Op. cit. 

8 Paul Bruns, op. cit. (p. 73), says seventeen cases, but there actually appears to 
have beeu eighteen. 
4 Op. cit. p. 710. 



CANCER OF THE LARYNX. 249 

years, whilst in 8 similar cases subjected to tracheotomy the mean of life 
was three years and nine months. Again, in 6 cases of epithelioma not 
tracheotomized, the average duration was one year and eleven months, 
whilst in 7 cases which were operated on the patients lived on an average 
four years. 

In cases which seem suitable, recourse may be had to extirpation of the 
larynx, but this operation should only be undertaken at the immediate 
request of the patient after the subject has been fully explained to him in 
all its bearings. 

The following description, for which I am mainly indebted to Dr. 
Foulis, 1 shows how extirpation should be effected : — A vertical incision 
should be made from the hyoid bone to the second ring of the trachea, 
and the front and sides of the larynx should be thoroughly freed and ex- 
posed by careful dissection, partly with the cutting blade of the scalpel, 
but as far as possible with its handle. Should there be any decided arte- 
rial hemorrhage, the necessary ligatures must be applied. The trachea 
should be then drawn forward with a hook and cut across, care being 
taken to avoid penetrating the oesophagus ; a syphon tube of vulcanite is 
then to be inserted into the windpipe. (In order that the syphon may fit 
accurately, it is well to have at hand several tubes of different sizes.) The 
upper and posterior attachments of the larynx should next be cut through, 
and in dissecting out the cricoid cartilage the risk of button-holing the 
gullet must be avoided by keeping the knife close to the cartilage. Some- 
times the whole of the larynx must be taken away, but in Dr. Foulis's 
case he was able to spare the superior cornua of the thyroid cartilage and 
half the arytenoid cartilages. If there is much hemorrhagic oozing from 
the raw surface it may be gently swabbed with a styptic solution ; but 
local applications are, if possible, to be avoided, as they are apt to excite 
reflex irritation and cause retching. When the surfaces have healed and 
the gap in the throat has contracted to some extent, Gussenbauer's arti- 
ficial vocal apparatus (see Tracheal Instruments) may be used. 

The operation, however, is not always of so simple a character as it 
has been described, for when the surgeon has made some incisions he may 
find that the disease is much more extensive than was previously supposed. 
Thus in one case Langenbeck was obliged to tie 40 arteries, to divide the 
lingual and hypoglossal nerves on both sides, and to cut away the two sub- 
maxillary glands and a large portion of the posterior half of the tongue. 
In a case of Billroth's, it was found necessary to remove the larynx, the 
three upper rings of trachea, the thyroid gland, the lower part of pharynx, 
and a large portion of the oesophagus. Extirpation of the larynx is in 
fact an operation in which, as Dr. Paul Koch s points out, " the skill of 
the surgeon is, in some cases, shown by the patient not dving under his 
knife." 

The following analysis of the annexed tables (pp. 251 — 254) shows the 
result of all the operations which have been performed up to the present 
time : Of nineteen cases operated on, one patient died six weeks after the 
operation from pericarditis, resulting from the passage into the medias- 
tinum of a bougie, used for dilating the oesophagus, which had undergone 
cicatricial contraction as a result of the operation ; eight patients died 
from collapse or pneumonia within a fortnight — in other words, directly 
after the operation, viz., 1 on the 2d day, 1 on the 3d day, and 1 on the 4th 



1 Lancet, October IP,, 1877. 

'-' Annates de l'Oreille, etc.. March, 1879. 



250 

day; 2 on the 5th day, 1 within " a few days," 1 on the 11th day, and one 
within 14 days. In seven instances recurrence took place within a few 
months after the operation, viz., once in 3 months, once in 4 months, twice 
in 6 months, and once each in 7 months, 9 months, and 10 months respec- 
tively. Three cases were cured, one of which was an example of carci- 
noma and two of sarcoma ; in one of the latter cases the patient died 
18 months after the operation from pulmonary and tracheal phthisis. In 
these three cases the disease was absolutely confined to the larynx, whilst 
in many of the others the neighboring tissues were also involved. It has 
already been shown that, owing to the arrangement of the lymphatic sys- 
tem in the larynx, disease of that part does not quickly infect the constitu- 
tion. This fact favors the prospects of extirpation of the larynx, when the 
neoplasm is confined to its cavity. In any case, the rescue of three pa- 
tients out of 19 (15.7 per cent.) from certain death must be regarded as one 
of the greatest triumphs of modern surgery. 

Reviewing the whole subject of treatment, our aim must be to pro- 
long life when possible, and in every case to promote the euthanasia 
when the inevitable end draws near. From the foregoing remarks it will 
appear that the first indication ean best be fulfilled by resorting to 
tracheotomy before the constitution has suffered from the impediment to 
free respiration. When deglutition is much interfered with, the patient 
must be fed by means of the oesophageal-tube, or by nutritive enemata. 
In order to relieve pain insufflation of morphia (gr. i to J mixed with 
powdered starch) may be employed once or twice daily with great advan- 
tage. By such topical applications alone it is often possible to keep the 
sufferer almost free from pain ; whilst at the same time swallowing is 
rendered easy, and the appetite frequently improves. Whatever means 
we may adopt for the treatment of the local disease, it must not be for- 
gotten to supplement them by general tonic and analeptic measures; and 
by well-considered dietetic and hygienic treatment an attempt should 
be made to preserve the integrity of the constitution as long as possible. 



Secondary Cancer. 

This affection scarcelv deserves the name here used, my experience 
being similar to that of Dr. Fauvel, who remarks that he has never met 
with a case of secondary cancer of the larynx originating in infection. 1 
It is very common, however, to find cancer involving simultaneously the 
posterior wall and sides of the oesophagus or lower portions of the pha- 
rynx, and at the same time the mucous membrane covering the posterior 
surface of the cricoid cartilage. Occasionally, also, cancer commencing 
in the sides of the pharynx or root of the tongue extends to the epi- 
glottis or ary-epiglottic folds. These are, in fact, illustrations of the con- 
tiguous extension of the disease, and have been sufficiently considered 
under Cancer of the Pharynx (page 60 et seq.). 



Op. cit. p. 748. 



CANCER OF THE LARYNX. 



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CANCER OF THE LARYNX. 



255 



Sarcomata. 

Sarcomata constitute a variety of growth, which is comparatively 
infrequent in the larynx, only five cases 1 having come under my notice. 
These growths may originate from any part of the mucous membrane of 
the larynx, and in one instance I met with a tumor of this kind (Fig. 
CG) situated on the posterior surface of the cricoid cartilage. Two of my 
cases occurred in men aged respectively sixty-four and forty-two ; the 
others in women, aged respectively fifty-three, forty-three, and thirty- 
seven. In one of these dysphonia had existed for twenty-three years. 
As a rule sarcomata rapidly attain a considerable size, 2 so much so, that 
in a relatively large proportion of the cases either thyrotomy or extirpa- 
tion of the larynx has been found necessary. In one of my cases the 
surface of the growth was quite smooth, but in the others it was mam- 
millated. The color is generally red, but in one instance it was partly 
yellowish, 3 and in another case it was darker than that of the neighbor- 





Fig. 66.— Sarcoma growing from the Posterior Surface of the Cricoid Cartilage : A, the growth in situ ; 
B, the growth after removal. 



ing mucous membrane. During life these tumors often cannot be distin- 
guished by their appearance from papillomata, and even after death, if 
extensive ulceration has taken place, the naked-eye appearances cannot 
be relied on. The true character of the disease cannot in fact be deter- 
mined witli certainty except by the microscopical examination of a por- 
tion of the neoplasm. 

These growths generally partake of the spindle-celled or fascicular 
character, but I recently met with an example of round-celled sarcoma, 
and the following is the microscopical report bv Dr. Stephen Mackenzie : 
•• Sections show the whole of the tissues infiltrated with small, round cells, 
completely filled by a nucleus, and with very scant}' and delicate reticulum. 
The cells are most numerous in the submucosa, where they pass in dense 
masses between the bundles of striated muscular fibres, and surround the 
blood-vessels and nerves. They do not much encroach on the mucosa. 
The epithelium covering the surface is in some places intact, but thick- 
ened ; in other places it is irregular, as though eroded and undergoing 



1 Op. cit. Appendix A, Nos. 59, 49, and 9."), and Trans. Path. Soc., vol xxi. The 
fifth case was that of a man, aged G4, whom I lately saw with Dr. Strong, of Croy- 
don. 

'-' Balassa : Wien. Med. Wochensehrift, No. 92, 18G8 ; also Ruppaner : New York 
Med. Journ., March, 1870; and Schroetter : Laryngol. Mittheil, Wien, 1875, p. 71. 

3 Laroyenne: Gazette hebdom., 1873, p. 780. 



256 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

proliferation. Nowhere are there epithelial protrusions into the mucosa. 
Some reticulated cartilage is cut across in the sections, and the cartilage 
cells have fallen out ; the nuclei of the fibres are unusually distinct." 

The prospects of the patient are much less satisfactory than in the 
case of benign growths, but more favorable than when cancer is present. 
In one case I succeeded in permanently removing the growth per vias 
naturales, 1 and Navratil, 8 Gottstein, 3 Tiirck, 4 and others have effected 
cures in this way. On the other hand, Balassa 5 attained success by thy- 
rotomy, and Bottini 6 and Foulis 7 both restored their patients to health 
by extirpating the larynx. 

If the growth cannot be entirely removed by intra-laryngeal treat- 
ment, either thyrotomy or extirpation of the larynx must -be selected 
according to the site and extent of the growth. 



SYPHILIS OF THE LARYNX. 

Latin Eq. — Syphilis laryngis. 
French Eq. — Syphilis du larynx. 
German Eq. — Syphilis des Kehlkopfs. 
Italian Eq. — Sifilitide della laringe. 

Definition. — The local manifestations in the larynx of constitutional 
syphilis, constituting the so-called secondary, tertiary, or hereditary phe- 
nomena, and giving rise to dysphonia or aphonia and sometimes to dysp- 
noea. 

Etiology. — The precise causes which predispose the larynx to an 
attack of syphilis are not clear ; but in many cases the disease is proba- 
bly attracted to the part through local weakness, either hereditary or 
acquired. The season of the year has a marked influence in causing the 
outbreak to take place in the laryngeal mucous membrane in the early 
stages, and to a less extent later on. Thus out of 118 cases of secondary 
syphilis, of which I have notes, 79 commenced between September 1st 
and March 31st, and only 37 between April 1st and August 31st, whilst 
out of 110 cases of tertiary syphilis 66 commenced in the six winter 
months, and 4-4 in the summer months. 

With respect to the frequency with which syphilis affects the larynx 
as compared with other parts, the statistics of Willigk * show that out of 
218 cases of syphilis in the dead subject, in 15.1 per cent, there was dis- 
ease of the larynx, in 10.1 per cent, the pharynx was affected, whilst the 
nose suffered in 2.8 per cent. Other observations give a somewhat differ- 
ent result. Out of 521 cases Engelsted 9 found the larynx affected only 25 
times. In 1,000 syphilitic patients Lewin 10 diagnosed a laryngeal affection 

1 Mackenzie : Op. cit. Case 95. 

2 Berlin. Klin. Wochenschrift, 1868, No. 49, p. 501. 

3 Wiener Medizin. Wochenschrift, Dec. 30, 1868, No. 105. 

4 Op. cit. pp. 576, 577. 5 Loc. cit. 
6 Loc. cit. 7 Loc. cit. 
8 Prager Vierteljahrschrift, xxiii. 2. p. 20, 1856. 

9 Virchow and Hirsch's Jahresbericht. Bd. ii. 1868, p. 585. 
10 Die Behandlung der Syphilis, Berlin, 1869. 



SYPHILIS OF THE LARYNX. 



257 



in 44. These figures are thus widely discrepant, and do not give any def- 
inite reply to the question at issue. In 10,000 consecutive cases of throat 
disease examined at the Throat Hospital, I found 308 cases of laryngeal 
syphilis, as compared with 834 in which the pharynx was affected. (See 
Table A.) 

With respect to age, most cases of laryngeal syphilis occur between 
twenty and forty, as will be seen on reference to Table B. Again, as re- 
gards the kind of syphilis most frequently met with in the larynx, Table 
A shows that tertiary phenomena are more common than secondary, being 
in the proportion of eighteen to eleven. From this it would appear that 
the larynx is most liable to be affected in patients in whom the constitu- 
tional malady has been of long standing. My colleague, Dr. Whistler, 1 
has, however, had a different experience, for Out of 170 cases of laryngeal 
syphilis, 88 corresponded to the secondary, and 82 to the tertiary stage. 



Table A. 

Showing Number of Cases of Syphilis in 10,000 Cases of Throat-disease 
seen at the Hospital for Diseases of the Throat." 1 



" Primary — Males . . . 
Females, 



Secondary — Males 348 

Females 143 



Pharynx ^ Tertiary — Males 176 

Females 163 



Hereditary — Males. . . 
Females. 



Larynx i 



r Tertiary — Males . . . 
Females. 



Trachea 



491 



339 



834 



Secondary — Males 84 

Females 34 

Tertiary— Males 120 

Females 69 

Hereditary — Males 1 

Females 



118 



189 



308 



1,145 



1 Med. Times and Gazette, Sept. 28, 1878. 

2 Although I have altogether met with seven cases yi primary syphilis of the pharynx, 
only one was seen among the 10,000 tabulated cases. 

17 



258 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



Table B. 



Showing Ages of Patients affected with Laryngeal Syphilis. 



Secondary. 

.. 
9 .. 

41 ... 

22 .. 

9 .. 

2 .. 

1 .. 



Males. 

Tertiary. 

under 15 

15 to 20 

20 to 30 15 

30 to 40 54 

40 to 50 33 

50 to 60 11 

60 to 70 6 



70 to 80 

84 



120 



Females. 
Secondary. Tertiary. 

2 under 15 

10 15 to 20 3 

15 20 to 30 17 

4 30to40 29 

2 40 to 50 15 

1 50 to 60 2 

60 to 70 3 



34 



69 



Table C. 
Showing the Particular Conditions observed in Syphilis of Larynx. 

Secondary. 



Congestion. 

Males 35 

Females 16 


Condylomata. 
33 
11 


Ulceration. 
16 

7 


Totals. 
84 
34 


51 " 




44 




23 


118 3 




Tertiary. 








Superficial 

Ulceration with 

Laryngitis. 


Deep and 
Extensive 
Ulceration 




Contrac 
tion, 


Gum- 
mata. 


Totals. 


Males 27 

Females 21 


42 




22 
5 


4 
1 


120 
69 


48 


107 




27 


5 


189 3 



1 In 17 of these cases there was at the same time congestion of the trachea, and in 
24 condylomata in the pharynx. 

■ In 81 of these cases there was at the same time secondary disease of the pharynx. 
3 Amongst these 189 cases, there were 7 of acute oedema, and 32 of chronic oedema. 



SYPHILIS OF THE LARYNX. 259 

JSymjytoms. — The phenomena of laryngeal syphilis vary, in different 
cases and in different stages, from the mildest to the most severe. Thus 
the patient may suffer merely from a slight inclination to clear the throat, 
or there may be extreme dyspnoea, advancing ultimately to such urgent suf- 
focative attacks, as to require tracheotomy. Cough is occasionally present 
in the early manifestations, but rare in the later stages. The vocal func- 
tion is generally impaired, and whilst at the commencement of the attack 
there is often only slight hoarseness, this may ultimately pass into com- 
plete aphonia. There maybe no odynphagia at first, but at a later period 
swallowing, in some cases, becomes almost impossible. The absence of pain, 
when the patient is not swallowing, is very characteristic. 

The pathological effects of syphilis in the larynx are extremely mani- 
fold, and comprise every kind of lesion that can be produced in the part, 
from a mere erythematous blush of the mucous membrane to great thick- 
ening, destructive ulceration, perichondritis, and necrosis of the laryngeal 
cartilages. 

In secondary syjihilis, condylomata are the most characteristic condi- 
tion, but chronic hyperaemia (without mucous tubercles) and superficial ul- 
cerations are often met with. As will be seen by reference to Table C, I 
met with -1-4 cases of condyloma among 118 patients suffering from the 
early symptoms of laryngeal syphilis; whilst among 88 patients in the 
same stage Dr. Whistler l saw 24 cases. On the other hand, Dr. Ferras a 
only found a single example in a hundred patients, Isambert 3 does not 
■consider that there is such a phenomenon as laryngeal condyloma, and 
both "Waldenburg 4 and Lewin 6 hesitate as to whether the characteristic 
mucous tubercles of syphilis are ever found in the larynx, being inclined 
to relegate the neoplasms usually described as such to the class of gum- 
mata. Again, whilst Gerhardt and Roth 6 found condylomata in 18 in- 
stances out of 56 patients suffering from constitutional syphilis, in a series 
of examinations at the Lock Hospital, I observed condylomata only twice 
among 52 patients. These wide discrepancies may perhaps be accounted 
for in a measure by the different periods of the year at which the observa- 
tions were undertaken, some having been made in the summer and some 
in the winter, but they are in part to be explained by the fleeting charac- 
ter of laryngeal condolymata, and by the different appearance which con- 
dolymata present in the larynx as compared with the pharynx — a differ- 
ence which renders them likely to be overlooked. In the larynx they gen- 
erally appear as smooth yellow projections, sometimes round, but more 
often oval, varying in diameter from three to seven millimetres, but in 
rare cases attaining a breadth of a centimetre. They are seldom so white 
as in the pharynx, and the surrounding mucous membrane is not gener- 
ally so congested. Moreover, they are less disposed to superficial ulcera- 
tion, and they generally disappear quickly — even without treatment. The 
•epiglottis and the inter-arytenoid commissure are the parts which I have 
most frequently found affected, but I have occasionally seen condylomata 
on the vocal cords. 

Superficial ulcerations of limited extent are, as already remarked, occa- 
sionally met with. They generally occur from six to twelve months after 
the primary infection, and heal after a few weeks' treatment. 

1 Ibid. - These de Paris, 1872. 

3 Annales des Maladies de Foreille, etc., t. ii. p. 239. 

4 Respiratorische Therapie, II. Aufl., 1872, p. 3GG. 
6 Loc. cit. p. 113. 

6 Virchovv's Archiv, Bd. xxxi. 1861, Hft. 1, § 7. 



260 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

In secondary syphilis, we also sometimes meet with very obstinate con- 
gestion of the laryngeal mucous membrane, but it is often impossible to tell 
whether this condition is really due to the syphilitic dyscrasia. I found 
marked congestion in 51 out of 118 cases of secondary syphilis. In every 
one of these 51 cases there were at the same time other well-marked symp- 
toms of constitutional syphilis — in 24 condylomata in the pharynx. As I 
pointed out long ago ! there is nothing characteristic about the congestion 
of syphilis, and I never consider a congestion syphilitic unless there are 
other well-marked evidences of the disease. Even then the laryngeal 
hyperemia is often the result of accidental catarrh, and in no sense due 
to the syphilis. On the other hand, M. Dance 2 has gone so far as to de- 
scribe roseolar, papular, and tubercular eruptions of the laryngeal mucous 
membrane, corresponding to similar manifestations on the skin. I have' 
never been able to verify these observations, nor have they been confirmed 
by other physicians. 

In tertiary syphilis the phenomena met with are ulceration, gummata, 
and cicatricial stenosis. The earliest, but not most frequent, symptom is 
obstinate superficial ulceration, accompanied by considerable hyperemia 
of the mucous membrane. Dr. Whistler 3 has well described this condi- 





Fig. 67.— Condyloma on the Fig. 68.— Thickening and TJ1- 

TJpper Surface of the Epiglottis. ceration of the Epiglottis. 

tion, under the name of " relapsing ulcerative laryngitis." When these 
superficial ulcers occur within a year of the primary affection, I have been 
in the habit of classifying them under the head of secondary syphilis,, 
though this is a mere arbitrary distinction. But when they appear three 
or four years after inoculation, they may fairly be regarded as tertiary. 
I have met with one instance of this affection in a patient who had been 
successfully treated fifteen years previously at Aix-la-Chapelle. The ul- 
ceration generally attacks the vocal cords, but I have frequently seen the 
inter-arytenoid fold, and occasionally the ventricular bands affected. 

Deep and destructive ulceration is, however, the characteristic morbid 
condition of the later stages of laryngeal syphilis. The ulcers may form 
three or four years after inoculation, but they sometimes occur twenty > 
thirty, forty, and even fifty years after the date of infection without the 
.occurrence of intermediate symptoms, and when, indeed, the primary cause 
may have even been altogether forgotten. Their effect is to produce 
great loss of substance, and the consequent changes in the form of the 
epiglottis and other parts of the larynx are very remarkable. The ulcers 
may form in any region of the larynx, but the epiglottis is the part most 
frequently affected — one of the most common conditions consisting of 
general thickening of the valve, with ulceration of the central portion or 
lateral free edge (Fig. G8). The upper surface is more often attacked 



1 Russell Reynolds' System of Medicine, vol. iii. p. 465. 

2 These de Paris, 1868. 

3 Med. Times and Gazette, 1878, Nos. 1480, 1484. 



SYPHILIS OF THE LARYNX. 



261 



than the under surface. Under these circumstances great dysphagia is 
usually experienced, but when the ulcers are healed, swallowing can gen- 
erally be effected without trouble, even though nearly the whole of the 
valve is destroyed. When the walls of the pharynx are also ulcerated, 
there is danger of the edges of the epiglottis uniting with them. This 
condition gives rise to one of the most dangerous forms of dysphagia, as 
well as to serious dyspnoea. The ulcerative process frequently destroys the 
mucous and submucous tissues to a very considerable extent, and some- 





Fig. 69.— Destructive Ulceration of 
the Epiglottis : Irregular Hypertrophy 
of the Left Ventricular Band and Ary- 
Epiglottic Fold. 



Fig. 70.— Thickening and Destruc- 
tive Ulceration of Epiglottis. 



times attacks the muscles, perichondrium, and cartilage. It is often asso- 
ciated with cedema, and is also not unfrequently followed by the forma- 
tion of false excrescences, which are most apt to occur on the inter-aryte- 
noid fold and the anterior surface of the posterior wall of the larynx, but 
are occasionally seen on the vocal cords. 

In these advanced stages syphilitic gummata are occasionally, though 
very rarely, formed in the submucous tissue and muscles of the larynx. 
They usually appear as round, smooth elevations (Fig. 71), generally of 
the same color as the rest of the mucous membrane, but sometimes of a 





Fig. 71.— Gumma. 



Fig. 72.— Gummata. 



yellow tint. They are most frequently found on the anterior surface of 
the posterior wall of the larynx, and generally in groups (Fig. 72). 
Mandl ' mentions the case of a negro suffering from severe pharyngeal 
syphilis, in whom numerous gummata, of a grayish yellow color, could be 
seen on the epiglottis and ventricular bands; and Norton 2 has described 
and figured a remarkable case, in which suffocation resulted from a gum- 
ma, the size of a pigeon's egg, in the right ary-epiglottic fold. The ulcer- 
ation which results from gummata is of the deepest and most destructive 
kind, and often penetrates to the perichondrium. 

Even when the ulcerative process is arrested, however, the danger 
does not cease, for the cicatrices often undergo such a degree of contrac- 
tion as to greatly lessen the calibre of the larynx. Indeed, the stenosis 



Maladies du Larynx. Paris. 1872, p. 700. 
Affections of the Larynx, London, 1875, p. 86. 



262 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

which so often results from tertiary ulceration is one of the greatest dan- 
gers of the disease. Sometimes the narrowing of the passage is caused 
by a web between the vocal cords (Fig. 73), and no less than six cases of 
this sequel of laryngeal syphilis have been reported by Dr. Elsberg, 1 of 
New York. In these cases there is generally complete aphonia. Some- 
times the crico-arytenoid articulation is enlarged and the joint stiff, and 
thus the vocal cord may be permanently fixed in the median line, at the 
side of the larynx, or at some intermediate position. Sometimes the cica- 
tricial process produces the most curious and irregular distortions and out- 
growths; indeed, so much is this the case, that it is occasionally almost im- 
possible to identify the various parts (Fig. 74). 

Hereditary syphilis is occasionally met with in children, though I 
have never seen a case in a child younger than seven years. In each of 
the five examples I have met with there was ulceration of the edge of the 
epiglottis, with exposure of the cartilage. The only instance of the dis- 




Fig. 73.— Web between Vocal Cords follow- 
ing Syphilitic Ulceration. 




Fig. 74.— Old Cicatrices on the 
Epiglottis : Contraction of the 
Walls of the Pharynx and Horn- 
shaped Outgrowth on Left Side. 



ease occurring in an infant that I am acquainted with is that observed 
by Isidor Frankl. 2 The subject was an infant, who was attacked with 
coryza two months after birth, and died from acute stenosis of the larynx 
in about three weeks. On post-mortem examination necrosis of the cri- 
coid and left arytenoid cartilage was found and syphilitic disease of the 
liver. 3 Rauchfuss 4 mentions that, in the "Post-Mortem Records of the 
St. Petersburg and Moscow Foundling Hospitals," there are a few cases 
of deep ulceration and perichondritis in infants of from two to three 
months old. 

Pathology. — The anatomical changes which the laryngeal structures 
undergo in syphilis have been investigated by Virchow, 5 who describes 
the phenomena with considerable detail. The general pathological fea- 
tures, however, have been so much touched upon in dealing with the 
laryngoscopic appearances that it is only necessary to make a few re- 
marks in this place. Condylomata are the result of a hyperplasia of the 
epithelium of the mucous membrane, generally attended with copious cell 
proliferation. They show little disposition to ulceration, except of the 
most superficial character, and generally disappear by a process of mole- 
cular absorption. The ulcers which form so quickly in tertiary syphilis,. 



1 Syphilitic Membranoid Occlusion of the Rima Glottidis, New York, 1874. 

2 Wiener Mediz. Wochenschrift, Nos. 69 and 70. 1868. 

3 A somewhat similar case is mentioned by Rollet, Diet, des Sc. Med. , art. Larynx, 
p. 693. 

4 Die krankheiten des Kehlkopfes und der Luftrohre im Kindesalter, Tubingen* 
1879, p. 210. 

5 Die krankhaften Geschwulste, Bd. ii. Part 2, p. 413. 



SYPHILIS OF THE LARYNX. 263 

result from a low form of inflammation which rapidly leads to liquefaction 
of tissue. Gummata are developed in the same way as in other organs, 
but they are very rare. 

Diagnosis. — Syphilitic diseases of the larynx can generally be recog- 
nized without difficulty, either by the general features of the case or by 
the laryngoscopic appearances. A few cases may be doubtful at first, 
but simple hyperemia is almost the only condition in which the judgment 
need remain long suspended. In the absence of other symptoms, it is 
impossible to tell whether a congestion is a simple catarrhal phenomenon, 
the outcome of syphilis, or the precursor of phthisis. In the early super- 
ficial ulcerations, the practitioner may likewise hesitate for a time be- 
tween catarrh and syphilis, but the progress of the case soon demonstrates 
its nature. 

The ulcers of tertiary syphilis may generally be easily distinguished 
from cancer and phthisis — the only affections in which error may occur 
through want of care. 

In syphilis the development of the ulcer is acute, often occupying a 
few days only. There is generally considerable irregular swelling of a 
decidedly inflammatory — often cedematous — character. When the epi- 
glottis is attacked, the upper surface is the most frequent site of the dis- 
ease. Above all it should be observed that the ulcer is most frequently 
solitary, and hence (except in the case of the epiglottis, where it is often 
central) generally unilateral, and that there are scarcely ever more than 
two separate ulcers. These ulcers are rather deep, irregularly round or 
oval in shape, and commonly have a diameter of a centimetre to a centi- 
metre and a half. 

In phthisis the development of the ulcers is slow, generally only oc- 
curring after the throat symptoms have existed for several months. They 
are nearly always preceded by swelling of the mucous membrane, which 
is of a somewhat uniform character, partaking of the appearance of an in- 
filtration, and extremely pale. The pallor of the mucous membrane is, 
indeed, a very characteristic condition. When the epiglottis is attacked 
it is the under surface which usually suffers; the ulcers are almost always 
numerous and bilateral; they are generally round and seldom more than 
two or three millimetres in diameter, except where the coalescence of 
several ulcers has produced a large breach, in which case they may attain 
the diameter of half a centimetre or more. In cases in which syphilis at- 
tacks phthisical patients the local symptoms are sometimes very obscure, 
and the diagnosis may be very difficult. 

In cancer, the development of the ulcer is intermediate, as regards time, 
between syphilis and phthisis, generally occupying a few weeks. As a 
rule the ulcer is preceded by the development of a growth, and there are 
nearly always nodular excrescences upon or around the ulcer. The neigh- 
boring mucous membrane is generally acutely inflamed. The ulcers are 
solitary, of irregular shape, and often attain a diameter of two or three 
centimetres. 

For further points of differential diagnosis the reader is referred to 
the articles on " Laryngeal Phthisis " and " Malignant Tumors of the La- 
rynx." Lupus, lepra, and glanders all give rise to ulcerations and thick- 
ening of the laryngeal structures; but they never occur until other gen- 
eral symptoms have made the nature of the disease only too manifest. 

Although the experienced laryngologist can at once feel sure that cer- 
tain ulcers are syphilitic, yet cases occasionally occur in which it is im- 
possible to arrive at a decision with the laryngeal mirror alone. The 



264 

diagnosis, under such circumstances, must be arrived at by attention to 
the history of the case, and by a consideration of the concomitant phe- 
nomena, such as the state of the pharynx, the skin, the lungs, and the 
general appearance of the patient. Should any doubt remain, it must 
soon be cleared up by watching the effects of treatment, syphilitic affec- 
tions rapidly yielding, if only for a time, to appropriate treatment. As 
Krishaber J has pointed out, false excrescences resulting from syphilitic 
ulceration can generally be distinguished from true growths by the sur- 
rounding hyperemia, which as a rule is altogether absent in the case of 
simple neoplasms. 

Prognosis. — There are few cases of syphilis in which the prognosis, at 
least as regards life, can be said to be absolutely unfavorable. Under ap- 
propriate treatment the most destructive ulceration can generally be ar- 
rested, although frequently at the expense of a considerable loss of sub- 
stance and great local deformity. Though stenosis may occur, in no class 
of cases are the immediate effects of tracheotomy so successful. It must 
be remembered, however, that where much ulceration of the vocal cords 
or necrosis of the cartilages has taken place, the voice must generally be 
looked upon as irrecoverably lost, whilst, if tracheotomy is called for, the 
patient will probably have to continue to wear the canula for life. The 
prognosis, as Krishaber 2 has pointed out, is unfavorable in proportion as 
the disease approaches the windpipe, and the most dangerous cases, as has 
been shown by Dittrich, 3 Porter, 4 and others, are those in which there is 
perichondritis of the cricoid and thyroid cartilages. Under these circum- 
stances a fatal issue may ensue from acute oedema or from extensive sup- 
puration of the surrounding soft parts. A rare instance is mentioned by 
Tiirck, 5 in which fatal hemorrhage took place from a large and deep ulcer 
of the left vocal cord. 

Treatment. — The mode of treatment recommended under " Syphilis of 
the Pharynx " (pp. 09 and 70) should be pursued when the larynx is af- 
fected. But here it may be remarked that the inhalation of an atomized 
solution of bichloride of mercury (1 in 1,000 or 500), first recommended 
by Demarquay and Schnitzler, has received such strong testimony from 
Waldenburg 6 and Massei 7 that there can be no doubt of its remarkable 
efficacy in obstinate syphilitic affections of the larynx. Severe cases of 
oedema generally yield to the free exhibition of iodide of potassium, but 
if there is much dyspnoea, scarification may be required, and if, in spite 
of this treatment, suffocation threatens, recourse must be had to tracheot- 
omy. When a web forms in the larynx it can sometimes be taken away 
with cutting-forceps, but Dr. Whistler's " cutting-dilator " (p. 194) has 
proved more serviceable to me in these cases. Electric cautery has been 
most successfully employed by Dr. Elsberg. 8 The success of any treat- 
ment, however, depends mainly on the density of the web; if it is thin no 
trouble is experienced, but when the membranous formation is tough and 
thick, the curative treatment is seldom of any avail, and I have not found 

1 Annales des Maladies de l'Oreille, etc., September, 1878. 

2 Gaz. hebdom., Nos. 45, 46, and 47, 1878. 

3 Prager Vierteljahrschrift, Bd. xxvii. 1850. 

4 Observations on the Surgical Pathology of the Larynx and Trachea. Cases 28 and 
29. Dublin. 

5 Loc. cit. p. 413. 

6 Die locale Behandlung der Krankheiten der Athmungsorgaue, Berlin, 1872, pp 
244 and 371. 

"' Patologia e Terapia della Laringe, Milano, 1877. 8 Op. cit. 



LARYNGEAL PHTHISIS. 265 

thyrotomy succeed where endolaryngeal methods have failed. In cases 
of stenosis from cicatricial contraction or disease of the cartilages, the 
process of dilatation described under " Perichondritis " should be pursued. 



LARYNGEAL PHTHISIS. 

Latin Eq. — Phthisis laryngea. 
French Eq. — Phthisie laryngee. 
German Eq. — Kehlkopfschwindsucht. 
Italian Eq. — Laringitide tuberculosa. 

Definition. — A chronic affection of the larynx attended by tumefac- 
tion and ulceration of the softer structures, and frequently by perichondri- 
tis and caries of the cartilages, arising from the local deposit of tubercle, 
which, as far as experience goes, is invariably preceded by a similar dis- 
ease of the lungs. 

History. — Petit ' was the first physician to call attention to this dis- 
ease, and his treatise, which appeared in 1790, was followed two years 
later by a more important work by Portal. 2 In 1802 Sauvee 3 collected 
these writings in a monograph which fully established the main features 
of the malady, but it was not till 1819 that Laennec 4 insisted on the tu- 
bercular nature of the disease. This view was disputed a few years later 
by Louis, 6 who, as is well known, attributed the ulceration to the corrod- 
ing effect of the sputa in pulmonary phthisis. The disease was subse- 
quently investigated by Trousseau, 6 Andral, 7 and Albers, 8 with consider- 
able minuteness, but Hasse 9 first described the deposit of tubercles in the 
mucous membrane of the larynx, with anything like detail. Rheiner, 10 
Rokitansky, 11 and Virchow, 12 subsequently insisted on the presence of tu- 
bercles in this part, and other observers have testified to their frequent de- 
posit, but it remained for Heinze, 13 in his recent exhaustive monograph, to 
place the pathology on a thoroughly scientific basis. This elaborate work 
cannot be said to have been shaken by Beverley Robinson, 14 who (apparently 
unaware of Heinze's labors) remarks that " the elevations which have been 
described in the larynx under the name of miliary tubercle are none other, 
as a rule, than small spherical swellings, which are occasioned by the fill- 
ing up with transparent fluid of the closed follicles of the submucous reticu- 
lum, which have been described by Heitler (Strieker's Med. Jahrbiicher, 
vol. iii. and iv. 1871) and Coyne ('Recherches sur l'Anatomie Normale de 
la Muqueuse du Larynx,' Paris, 1874)." 

1 De phthisi laryngea Dissertatio, Montpellier, 1790. We have not included a case 
of ulceration of the larynx described by Morgagni (De Sedibus, vol. 1, p. 10), as the 
lungs were not affected in this instance. 

- Traite de la Phthisie Pulmonaire, 1792, p. 819. 

3 Recherches sur la Phthisie Laryngee, Paris, 1802. 

4 Traite de 1' Auscultation, etc., Paris. 1819. 

5 Recherches sur la Phthisie, Paris, 1825. 

6 Trousseau et Belloc : Trait*'* de la Phthisie Laryngee, Paris, 1827. 

I ( 'Unique Medicale, t. ii. Paris, 1829. 

8 Pathologie und Therapie der Kehlkopfskrankheiten, Leipzig, 1829. 

9 Spec. Pathol. Anatoraie, Leipzig, 1841. 

10 Virchow's Archiv. Bd. v. p. 219. 

II Lehrbuch d. pathol. Anatomie, iii., Wien, 1861. 
12 Geschwiilste, ii., Berlin, 1864-65. 

1S Die Kehlkopfschwindsucht, Leipzig, 1879. 

J4 Ulcerative Phthisical Laryngitis, American Journ. Med. Sciences, April, 1879. 



266 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

Etiology. — The exciting cause is almost invariably to be found in the- 
previous existence of pulmonary phthisis. Common experience shows 
that in the case of adults, at least, tubercle is rarely, if ever, found in any 
organ or tissue of the body, unless it has been previously deposited in the 
lungs, and the larynx proves no exception to this rule. It is true that it 
cannot be disproved that the deposit of tubercle in the laryngeal mucous 
membrane may not precede that in the lungs; and it impossible that the 
larynx may be the seat of the disease without the lungs ever becoming 
affected. All observation, however, points in the opposite direction, for 
in nearly every case of laryngeal phthisis, disease of the lungs can be de- 
tected with the stethoscope. Dr. Heinze remarks that during life it is- 
difficult to determine the existence of primary tuberculosis of the larynx, 
because on the one hand the most careful physical examination may fail to 
detect small cheesy deposits or indurated spots in the lungs, especially 
when they are of long standing and deeply situated, and because, on the 
other hand, it is impossible by means of the laryngoscope to be absolutely 
sure that any deposit in the larynx is actually tubercular. Even when the 
tubercular diathesis is strongly marked, however, and when other organs 
are affected with tubercle, deposit is not found in the larynx unless the 
lungs are at the same time the seat of this disease. In 100 cases of pul- 
monary phthisis which I examined at the London Hospital in the second 
and third stages, I found laryngeal phthisis in 33 ' cases. In 1,226 cases 
of pulmonary phthisis occurring at the Pathological Institute of Leipzig 
between the years 1867 and 1876, there was, according to Heinze, laryn- 
geal ulceration in 376 cases, or 30.6 per cent. 

The predisposing circumstances are sex and age, men being much 
more frequently affected than women, and the vigorous period of adoles- 
cence — twenty to forty — being the time of life at which the disease is 
most common, the greatest number of cases, however, occurring between 
twenty and thirty. In 500 cases of marked laryngeal phthisis which I 
examined during life there were 365 males and 135 females, or 2.70 males 
to one female, and in 100 autopsies I found the same ratio, the propor- 
tion being 73 males to 27 females. From an analysis of 70 cases, Dr. 
Marcet a states that twice as many men as women are affected. Dr. 
Heinze gives the proportion of males to females as 33.6 to 21.6. The 
following tables illustrate some of the points referred to. 



Table A. 

Sex and age in 500 cases of Laryngeal Phthisis examined during Life by 

the Author. 



Males. 



15 to 20 13 

20 to 30 149 

30 to 40 115 

40 to 50 61 

50 to 60 27 



Females. 

Ages. 

Under 15 1 

15 to 20 21 

20 to 30 45 

30 to 40 47 

40 to 50 21 

50 to 60 



1 In these 100 cases of pulmonary phthisis the laryngeal mucous membrane was 
normal twenty-nine times, anasmic five times, congested twenty-seven times, superfi- 
cially ulcerated five times, aphthous once, infiltrated twenty times, infiltrated and 
ulcerated thirteen times. 

2 Lancet, February 27, 1875. 



LARYNGEAL PHTHISIS. 267 

Table B. 1 
One Hundred Autopsies in Cases of Laryngeal Phthisis by the Author. 

Females. 



Males. 

Ages. 

5 to 10 1 

10 to 15 3 

15 to 20 11 

20 to 30 31 

30 to 40 23 

40 to 50 3 

50 to 60 1 



Ages. 

5 to 10 

10 to 15 1 

15 to 20 5 

20 to 30 11 

30 to 40 8 

40 to 50 2 

50to GO 



Table C. 

Cases occurring in the Pathological Institute of Leipzig r , from 1867 to- 

1876. 

Pulmonary Laryngeal 
Phthisis. Ulceration. 

Under 1 year 13 1 

ltolO . .. 39 4 

11 to 20 92 23 

21 to 30 406 130 

31 to 40 303 112 

41 to 50 179 67 

51 to 60 104 27 

61 to 70 53 9 

— to 70 25 3 

Of unknown age 12 

Although my statistics only include one case of laryngeal phthisis; 
un»!er ten years of age, and Heinze's only four, I have met, in addition to 
these, with three cases of children between five and ten years of age, and 
four between ten and fifteen, and Rheiner 8 has reported a case at four 
years. 

Pursuing the etiology somewhat further, the subject is beset with 
great difficulties, and it has not yet been determined what is the cause of 
the secondary deposits in the larynx. Louis, 3 whilst maintaining that 
ulceration, when present, was caused by the destructive action of the pul- 
monary sputa, nevertheless admitted that the ulceration bore no relation 
to the irritating quality of the expectoration, and that there were many 
cases of extensive destruction of the lungs, and old tubercular cavities, 
without any laryngeal ulceration. It has been pointed out by other phy- 
sicians that the laryngeal ulceration occurs in some cases before any cavi- 
ties are formed, and also in some cases in which there is scarcely any ex- 
pectoration. It has been urged that ulceration of the larynx is not gen- 
erally present in cases of gangrene of the lung, where the pus is probably 

1 None of the cases contained in Table A are included in Table B. 

2 Loc. cit. 3 Op. cit. 



268 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

of a more irritating nature, but it must not be forgotten that gangrene is 
more likely to occur in the non-scrofulous than otherwise, and, hence, this 
argument falls to the ground. Further, the fact that the ulcerations in 
the larynx are scattered is opposed to the theory that the disease could be 
oaused by the expectorated mucus which comes in contact with all parts 
of the larynx. That the disease originates from the corrosive action of 
the sputa is, moreover, rendered improbable by the pathological investi- 
gations of Heinze, wbo shows (see Pathology) that the destructive pro- 
cess commences from w T ithin, not from without. Rheiner's ! theory that 
the ulceration is caused by friction has also been disposed of by Heinze, 
who has pointed out that the catarrhal inflammation, w T hich almost in- 
variably precedes ulceration, prevents the vocal cords coming together, 
and that the vocal processes which are stated by Rheiner to be a frequent 
site of the disease do not actually come in contact with one another. It 
may be added that the under-surface and base of the epiglottis, which are 
comparatively free from attrition, are more frequently attacked by tuber- 
cular ulceration than the edges which are much exposed to friction. Some 
physicians suppose that the constant hacking cough, which is a charac- 
teristic symptom of tubercular disease of the lungs, causes the morbid 
process to be developed in the larynx. 2 It is only, however, from a theoret- 
ical standpoint that this cause can be upheld as being concerned in the 
production of laryngeal phthisis. 

In some cases, secondary tubercle is developed in the intestines, in 
others in the larynx; sometimes the kidneys, sometimes the spleen are the 
parts secondarily implicated; but the reason why tubercle in any given 
case shows a greater preference for one organ than for another is probably 
due to weakness on the part of the organ attacked. The weakness of the 
larynx ma} r either be congenital, or it may be acquired, owing to that 
organ having been frequently attacked by inflammatory affections of a 
more or less pronounced character. Thus, a great many patients suffering 
from laryngeal phthisis date the commencement of their illness from a 
severe catarrh. A chronic weakness of the vocal organ may also be de- 
veloped by persistent overexertion of the voice, as in the case of public 
speakers, singers, auctioneers, military and naval officers, etc. Under these 
circumstances some special laryngeal affection is ultimately induced, 
which, if tuberculosis be present in the system, is very likely to culminate 
in the local phenomena of laryngeal phthisis. Dr. Marcet 3 did not, how- 
ever, find the excessive use of the voice a frequent cause of the disease in 
his seventy cases, but attributed its occurrence rather to sedentary in-door 
occupations, which I have shown (see Catarrhal Laryngitis) to be a fre- 
quent predisposing cause of subacute inflammation of the larynx. 

In returning to the subject of the possible primary deposit of tubercle 
in the laryngeal mucous membrane, I must again refer to Dr. Heinze's 
valuable labors. In addition to collecting and analyzing the records of 
the Leipzig Pathological Institute for many years, this pathologist, during 
the year 187G, made most minute pathological investigations upon 50 
bodies of persons who had died of pulmonary phthisis. In 47 of these 
there was tubercular ulceration of the larynx or trachea, and in no in- 
stance did it appear that the deposit in the larynx or trachea had preceded 
the pulmonary deposit. " No case of primary laryngeal phthisis," he 



1 Loc. cit. 

2 Diet, des Sc. Med., Paris, 1868. Article Larynx, by Krishaber and Peter, p. 666. 

3 Loc. cit. 



LARYNGEAL PHTHISIS. 269 

observes, " has ever been published in which post-mortem examination 
has shown that there was true tubercular ulceration of the larynx as a 
primary affection whilst the lungs were intact." He further remarks, 
" that it is 2^ossible that tubercle may first be deposited in the larynx, and 
afterward in the lungs, but this is difficult to establish, as cases of simple 
laryngeal phthisis would only come under observation through some inter- 
current acute affection of some other organ than the lungs, or from some 
fatal accident. Asa rule, on post-mortem examination, the lung affection 
is much more advanced and of much older date than the laryngeal dis- 
ease." I formerly published some fatal cases which I believed were ex- 
amples of laryngeal phthisis, in which the lungs were healthy, but I must 
freely admit that I formed my opinion from naked-eye appearances, not 
from histological examination. 

Symptoms. — At the commencement there is nothing characteristic 
about the symptoms of this malady. The usual phenomena of chronic 
laryngitis are present, but the laryngeal symptoms are to some extent 
masked by those dependent on the pulmonary condition. The following 
table shows the proportionate frequency of some of the symptoms : 



Table D. 

Symptoms in 500 Cases of Laryngeal Phthisis examined during Life. 1 

Aphonia 123 

Dysphonia 337 

Dysphagia 151 

Sore throat 62 

Stridulous breathing 8 

Great dvspncea requiring tracheotomy 3 

Cough 427 

Shortness of breath on slight exertion 415 



Hoarseness is generally present in the early stages, aphonia when the 
disease is advanced, but sometimes there is functional aphonia from the 
very first. 2 It will be seen from the printed table above that the vocal 
function was more or less impaired in 460 out 500 cases, i. e., in 92 per 
cent. In 100 cases of pulmonary phthisis examined at the London Hos- 
pital, in which there was no laryngeal phthisis, there was hoarseness, 
either constant or occasional, in 37 cases. In 1 of these there was par- 
alysis of the right recurrent nerve, in 4 the aphonia was due to imperfect 
tension, or insufficient adduction of the vocal cords, whilst in the re- 
mainder the cause of the impaired function was slight congestion of the 
vocal cords. 

Dysphagia occurred in nearly a third of my cases, i. 6., in 30.2 per 

1 The notes of nearly 200 of these cases were taken from me in 1873 and 1874 by 
Dr. Porter, of St. Louis, at that time acting as one of my clinical assistants. This 
physician has since written some excellent practical directions (hereinafter referred 
to) as regards the treatment of laryngeal phthisis. 

- In the year 18Go I examined a number of cases of pulmonary phthisis, in which 
the voice was affected, at the Brompton Hospital, and found the impairment of func- 
tion to be neurotic (due to loss of power of the adductors or tensors) in nearly one- 
third. Hoarseness and Loss of Voice in Relation to Xervo-muscular Affections of 
the Larynx, 2d edition, 1S78, page 8. 



270 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

cent. This symptom does not occur so frequently in any other chronic 
disease of the throat. The difficulty of swallowing is of three kinds. In 
the early stage it generally partakes of the character of odynphagia, 
being due to pain in swallowing. Later on there is often obstruction 
from the enlarged epiglottis and the swollen ary-epiglottic folds; whilst 
at a still more advanced period the difficulty of swallowing is due to the 
imperfect closure of the larynx, and the consequent passage into that 
tube of the ingesta. 

Sore throat, that is to say, a feeling of soreness occurring indepen- 
dently of deglutition, was present in 12.4 per cent, of my cases. 

Cough was a marked symptom in 427 of my 500 cases. Though 
nearly always present to a greater or lesser extent, it is not generally a 
prominent symptom in the early stage. It may be very slight and occa- 
sional, or it may be frequent and irritating — what is called "a tickling 
cough." In the later stages of the disease, however, there are often 
violent paroxysms of the most prolonged and exhaustive character. 

Short?ie$s of breath occurred in 415 of my 500 cases. This symptom 
is partly due to the disorganized condition of the lungs, and partly to 
the inability to close the glottis. The latter condition has been described 
by Ziemssen ' as phonative loss of breath. Laryngeal dyspnoea occurred 
in 2.2 per cent., necessitating tracheotomy in .6 per cent. 

Expectoration varies both in quantity and quality, and, in fact, depends 
more on the condition of the bronchial tubes and lungs than on that of 
the larynx. 

Some of the other phenomena which accompany laryngeal phthisis are 
characteristic, the cachectic look of the patient being often very marked, 
•even at the beginning of the disease. On laryngoscopic examination, the 
appearance of the organ is seen to vary considerably at different periods 
in the course of the malady, but generally has some special features by 
which its true nature may be recognized. In cases of pulmonary phthi- 
sis pallor of the mucous membrane is often noticed, and Dr. Semeleder 
first called attention to anaemia of the larynx as a frequent pretuber- 
cular condition of that organ. This view has since been maintained by 
Sawyer, 8 Solis Cohen, 3 Semon, 4 and others, and it is probable that fee- 
ble local nutrition predisposes to the deposit of tubercle. The existence 
of marked anaemia of the larynx should always induce the practitioner to 
make a careful examination of the apices of the lungs. It must not 
be forgotten, however, that in all anaemic and chlorotic states of the sys- 
tem the laryngeal mucous membrane participates, and it is only in the 
non-existence of other conditions that tubercle must be suspected. In 
any case, however, the anaemia often gives way to congestion — a conges- 
tion which is by no means characteristic or distinguishable from chronic 
catarrh. On the other hand, when the deposit of tubercle has taken 
place to some considerable extent, the appearance is often pathognomo- 
nic. The ary-epiglottic folds look like two large, solid, pale pyriform tu- 
mors, the large ends being against each other in the middle line, and the 
small ones directed upward and outward. The surface is, as already re- 
marked, generally pale, but there may be accidental congestion. The 
inter-arytenoid fold is lost in these swellings, which interfere with the 
action of the arytenoid cartilages, and thus prevent approximation of the 
vocal cords. It must not be expected that this peculiar swelling of the 



1 Loc. cit. ' Lancet, January 30, 1875. 

3 New York Med. Record, No. 2G, 1878. 4 London Med. Record, April 15, 1879. 



LARYNGEAL PHTHISIS. 



271 



ary-epiglottic folds will be found in every instance; but it will be met 
with in by far the greater number of cases, and when present is typical 
of laryngeal phthisis. The epiglottis may be thickened, but sometimes 
shows no signs of deposit. Such are the appearances which are typical 
of the first stage of laryngeal phthisis. In the second stage ulceration 
takes place, and the ulcers are almost always small and scattered. It will 
be observed that I only recognize two stages in laryngeal phthisis, viz., 





Fig. 75. — Laryngeal Phthisis, showing 
the pyriform swelling of the ary-epiglot- 
tic folds. 



Fig. 76.— Incipient Laryngeal Phthi- 
sis involving the left ary-epiglottic fold, 
but before the true pyriform swelling 
is developed. 



the first stage in which deposit takes place, and the second stage, in which 
ulceration occurs. It will, perhaps, simplify matters if the morbid changes 
in the separated parts are now described in detail. 

Ary-epiglottic Folds. — Sometimes the ary-epiglottic fold of one side 
is alone affected (as in Fig. 77), and at an early stage the projection of the 
cartilages of Wrisberg and Santorini interferes with the distinctly pyri- 





Fig. 77. — The same case more de- 
veloped, showing one ary-epiglottic 
fold of the pyriform shape (as far as 
the woodcut is concerned the drawing 
might answer as well for oedema, aa 
the density of the swelling cannot be 
shown). 



Fig. 78.— Laryngeal Phthisis, showing 
the turban-like thickening of the epiglot- 
tis and the swollen mucous membrane 
over the arytenoid cartilages. 



form shape of the tumors (Fig. 76), but when fully formed they are very 
characteristic of the disease. As the affection progresses, a certain 
amount of oedema is almost always superadded to the more solid deposit. 
Epiglottis. — The epiglottis is not unfrequently thickened and ulcer- 
ated, and sometimes it is so much enlarged as to prevent an inspection 
of the parts below. In other cases, the valve assumes an altered position 
and covers the opening of the larynx, a phenomenon which, as Dr. Krish- 
aber ' has pointed out, is often met with at quite an early period of the 
disease; at a more advanced stage its shape is often somewhat turban- 
like (Fig. 78), the normal contour and surface marks having completely 
disappeared. In addition to the thickening, the epiglottis is, in fact, 
often rolled backward on itself, so that the free edges cannot be seen in 



Loc. cit. p. G50. 



272 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA 



the laryngeal mirror. In other cases where they are visible, the cartilage 
is exposed from ulceration (Fig. 80). Sometimes there is general thick- 
ening, with scattered points of ulceration (Figs. 79 and 80). The pres- 
ence of a great number of small, scattered, and obstinate ulcers is indeed 
very characteristic of the disease. 

Ventricular Bands. — Thickening and ulceration of the posterior part 
of the ventricular bands can sometimes be seen, but the disease may make 
considerable progress in this site without coming into the field of "vision. 
By placing the mirror somewhat obliquely, and slightly twisting the 
patient's neck, ulcers in this situation can, however, be detected. 

Vocal Cords. — Slight thickening of the vocal cords is an early phe- 
nomenon, and ulceration is very frequent, the most common position being 
at the processus vocalis. The elastic tissue is often exposed, and not un- 
frequently eroded. 

In the most advanced stages of laryngeal phthisis, the ulcerative pro- 
cess often makes such ravages that the larynx becomes almost denuded 
of mucous membrane, whilst the greater part of the epiglottis is eaten 





Fig. 79.— Laryngeal Phthisis, showing great Fig. 80.— Laryngeal Phthisis, show- 

thickening, with scattered ulcers. ing destruction "of a large portion of 

the epiglottis, and general ulceration. 

away. At the same time perichondritis and destruction of the cartilages 
often occur, In the absence of the physical signs of pulmonary phthisis, 
it is not always possible to tell whether a case of laryngeal ulceration is 
tubercular or not, especially in the absence of marked infiltration. Though 
Ter Maten ' and Tiirck have described the laryngoscopy appearances of 
tubercle, Heinze very properly declines to accept these observations, re- 
marking that even in the case of a larynx fresh from the body, it is im- 
possible to determine absolutely with the naked eye whether the ulcera- 
tion is tubercular or not, although the matter can be easily settled with 
the microscope. Paralysis of one of the vocal cords is sometimes pres- 
ent, the right recurrent nerve being occasionally pressed on when the apex 
of the right lung is diseased (see Paralysis of the Recurrent Nerves), and 
the left being sometimes impinged on by an enlarged gland. These, 
however, are rare phenomena. More often the immobility of one of the 
cords is of a purely mechanical character, due to general infiltration of the 
tissues. 

Pathology. — Secondary tubercular deposit in the larynx is a very com- 
mon sequel to pulmonary phthisis. According to Heinze, the larynx is 
next most frequently affected after the intestines, but Willigk's statistics 
place the mesenteric glands as well as the intestines above the larynx. 
In Heinze's 1,226 cases of pulmonary phthisis, tuberculosis occurred in 
the following descending scale: In the intestines, in 630 cases; in the 



1 Nederlandsch Tijdschrift voor Geneeskunde, Treede Afdeelig, I860, p. 86. 



LARYNGEAL PHTHISIS. 273 

larynx, in 376 ; ' liver, 286; kidneys, 150; pleurae, 137; spleen, 120; 
glands, 106; trachea, 99; peritoneum, 95; membranes of the brain, 43; 
sexual organs, 21; omentum, 21; tongue, 18; bronchi, 15; pharynx, 14; 
vesical organs, 12; brain, 12 ; pericardium, 11 ; tonsils, 8; mesenteric 
glands, 7; oesophagus, endocardium, supra-renal capsules, each 5; knee- 
joint, thyroid glands, outer coat of aorta, muscular substances of heart, 
of each 1. According to the statistics of Willigk, 2 made in the Prague 
Pathologico-i^natomical Institution, out of 1,317 cases of tuberculosis, 
there were 656 of the intestines, 237 of the mesenteric glands, 182 of the 
larynx, and 242 of other organs. The difference in these two sets of 
statistics is probably to be accounted for by the more careful microscopic 
examinations of Heinze. 

The laryngoscopic appearances of laryngeal phthisis have already been 
described, but the broad features of the pathology must again be pointed 
out before the minute changes are detailed. Structural changes are often 
preceded by obstinate hyperemia, which cannot be distinguished from 
chronic catarrhal laryngitis. 

Thickening of the tissues constitutes, when due to the deposit of tuber- 
cle, the true first stage (that of deposit), the amount of thickening varying 
in different situations, but the ary-epiglottic folds and epiglottis being 
more frequently infiltrated and swollen to a greater extent than any other 
parts; in the second stage small ulcers form, which afterward coalesce and 
produce larger ulcers (the secondary tubercular ulcers of Rokitansky). 
Chronic oedema almost always accompanies or follows the tubercular de- 
posit. In 500 cases of laryngeal phthisis which I examined during life, 
there was evidence of oedema 165 times. In many of these cases the ob- 
servation was made in an early stage of the malady, and no doubt the 
tendency to oedema increases as the disease advances. Thus in 100 autop- 
sies of laryngeal phthisis, oedema — circumscribed or general — was pres- 
ent in 71 instances. The following table shows the results, as regards 
thickening and ulceration, in the different parts of the larynx: 



Table E. 

Pathological Results in 500 Cases examined during Life. 

Arytenoid Carti- v . ., Inter- 
Epiglottis. lageorAry- Voc _ al Vent. arytenoid 
epiglottic Fold. Cords - Band - Folds. 
Thickening... 175 397 173 113 101 
Ulceration 111 52 157 97 92 

^ Thickening, either general or circumscribed, was present in every case; 
thickening with ulceration in 193 cases. In my 100 cases examined after 
death, however, I found ulceration in 97 cases, as will be seen from the 
annexed table: 



1 This is the number of cases of ulceration of the larynx ; about fifty of these, oi 
14 per cent., were probably non-tubercular. 
% Prager Vierteljahrschrift, ii., 1856. 

18 



274 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



Table F. 

Post-mortem (Naked Eye) Appearances of Mucous Membrane in IOC 

Cases. 







Arytenoid Carti- 




Epiglottis. 


lage or Ary- 
epiglottic Fold. 


Thickening 


...81 


97 


Ulceration . 


...69 


78 



Vocal Vent. 
Cords. Band. 



Inter- 

arytenoid 

Folds. 

81 95 93 

89 91 91 

There was also necrosis, with separation of perichondrium by pus, in 
15 cases; perichondritis (thickening of perichondrium) in 11 cases, with- 
out apparent separation of perichondrium; and ossification of cartilages 
in 79 cases. 

Tubercular infiltration, according to Heinze, is present in about half 
the cases of laryngeal phthisis, but it has appeared to me to occur much 
more frequently. The deposit can often be recognized macroscopically as 
a smooth, elastic, yielding swelling of grayish white or grayish yellow color, 
which on its surface frequently shows a whitish yellow deposit, either col- 
lected in little masses or confluent. Microscopically the appearance is very 
characteristic. There is general thickening of the diameter of the mucous 
membrane (equally affecting both the mucosa and submucosa), so that it 
becomes from three to four times its ordinary thickness. This is most con- 
spicuous in the covering of the arytenoid cartilages, in the ary-epiglottic 
folds, and in the epiglottis. As regards the epithelium, until ulceration 
has actually taken place there is no great change, even when there is con- 
siderable deposit of tubercle beneath the epithelial structures — a circum- 
stance which is opposed to the view that tubercular infiltration is due tc 
the corrosive action of the sputa. The deposit consists of tubercles, which 
are made up of more or less circumscribed collections of cells of various 
shapes and sizes, having a somewhat concentric arrangement upon a scaf- 
fold of lymphoid reticulum. The tubercles, some very small, and some as 
large as a millet-seed, have frequently, in their centre, a "giant cell," 
around which are lymphoid cells, and some few larger cells with nuclei of 
high refracting power. The tubercular deposit is found both in the mu- 
cosa and in the submucosa, but always above the layer containing the 
mucous glands. It is sometimes deposited uniformly through the thick- 
ness of the mucous membrane, but is much more commonly found in the 
most superficial layer of the mucosa, immediately beneath the epithelium. 
In the deeper layers of the mucosa both the tubercles and the round cells 
are less abundant. Occasionally we meet with deposits of tubercle near 
the epithelium, whilst the tissue between the deposit and the epithelium 
contains a few round cells and many capillary vessels, but no tubercle — a 
circumstance which further tends to show that the tubercular ulcer origi- 
nates through perforation from within, not from without. The tubercle 
is of different date: sometimes it shows fatty degeneration at its centre, 
sometimes such complete caseation that only its walls remain. 

In describing the microscopical appearances I have made large use of 
the valuable work of Heinze already referred to. Until the publication 
of his essay I had not given my attention to the minute histology of this 
important disease, but since then my brother, Dr. Stephen Mackenzie, has 
made careful microscopical examinations of my recent pathological speci- 



LARYNGEAL PHTHISIS. 



27o 



mens, and has furnished me with the following report, which, it will be 
seen, fully confirms Heinze's observations: 

" In the specimens submitted to me, the epithelium presents no im- 
portant alterations. The mucosa and submucosa are greatly swollen 
and oedematous, and infiltrated throughout with lymphoid cells, which 
occur both as a general infiltration and in more or less circumscribed col- 
lections with a somewhat concentric arrangement. These collections are 
supported by a delicate reticulum, and their centres are often pale and 
necrotic. The circumscribed collections of lymphoid cells frequently en- 
close two, three, or more large plates or spheres of protoplasm contain- 
ing: a srreat number of ve-, 
sicular nuclei and delicate 
peripheral filamentous pro- 
cesses (giant cells). The 
appearances are, indeed, 
similar to that which is seen 
in tubercular diseases wher- 
ever occurring. In the lar- 
yngeal mucous membrane 
there appears to be a gene- 
ral infiltration (such as is 
commonly observed in 
chronic inflammation), as- 
sociated with more or less 
well-defined and often co- 
alescing tubercles. As re- 
gards the position of the 
latter, they occasionally ap- 
pear to be placed laterally 
to arteries, but this may be 
only accidental, the irregu- 
lar course of the vessels 
in the laryngeal mucous 
membrane not being favor- 
able to tracing any relation- 
ship. Sometimes they are 
close to the dilated ducts 
of the mucous glands, which 
show some alterations. In 
parts both acini and ducts 
are dilated, 



a. 




a' 



Fig. 81. — Section thromrh the Right Ary-epiglottic Fold, show* 
ing Tubercles in Bub-mucosa : a, Tubercles ; b, Mucous Glands. 



and whilst containing small round cells, they are surrounded 
by a considerable amount of cellular infiltration. The tubercles occur at 
all depths from close beneath the epithelium to near the cartilages. None 
are free on the surface, except where it is ulcerated. 

The cartilaginous framework of the larynx shows the effects of tuber- 
culosis in various ways. Perichondritis is characterized by the abundance 
of pus-cells between the bands of the perichondrium. The suppuration is 
sometimes so active that the whole structure may disappear, and the car- 
tilage lie loose in an abscess. The intercellular substance of the hyaline 
cartilages first becomes opaque, and afterward shows signs of fatty degen- 
eration, whilst the elastic fibres of the epiglottis become infiltrated with 
pus, and the cartilage cells disappear by fatty degeneration. According 
to Heinze, perichondritis only occurs when the tubercular process ap- 
proaches the cartilages or reaches the perichondrium, neither perichondri- 



a ^; i ; . , ^/o/" certain that the apparently sound 

"' ^J/A^VoV •// © lung is intact; and further, that 

/.f? r ° .'v^^ on post-mortem examination it 



276 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

tis nor chondritis being over met with in cases of catarrhal ulceration of 
the larynx. I feel convinced, however, that this view is incorrect, and 
that perichondritis occasionally supervenes in cases of long-standing but 
simple chronic laryngitis. Heinze maintains that the largest swellings 
met witli in laryngeal phthisis are not due to perichondritis, but to tuber- 
culosis of the mucous membrane, and that in cases of perichondritis the 
tumefaction is often very slight. 

Ulceration is the common sequel of the deposit of tubercle in the mu- 
cous membrane of the larynx. Friedrich has stated that the larynx is 
most frequently affected on the same side as the lungs, but I have not 

found this to be the case. On 
O o^ this subject Heinze remarks that 

/^^'r^v~°^t~V/^ ; during life it is impossible to be 

r-Mr- i§ ' "h '-■ 

l f c °), [ -> ^Iqi: gp -:~,sj- o is rare to find the ulceration en- 

G'GG jGQG^ tirely confined to one side. In 

f r - _ y '" . -^&.j3i* r - fifty cases of pulmonary phthisis 

;/<?■ ^t l ^^e$Ss in which there was laryngeal ul- 

>^ G , Wf ^O J ceration, he observed tubercular 

o'fe^^, \ rr _G .'•'/ ulceration of the larynx in forty 

^^ ( 7^- '" Gz ~~ .' y cases, non-tubercular ulceration 

Cf'^GzL .^oG '^ of the larynx (but tubercular ul- 

c <?.> /%?&&• Jtd ceration of the trachea) in seven, 

„ M „ .. , .J? 7 ,,. t- an( i three in which there was no 

Fig. 82.— Portion of one of Tubercles in preceding Fig. , i • m i i i 

more highly magnified to show Giant Cells. tuberculosis. 1 llbercular Ulcer- 

ation is characterized by the pres- 
ence of tubercles in the edges or bases of the ulcers, but ulcers must also 
be regarded as tubercular, even though no characteristic tubercle is pres- 
ent, when giant-cells are found (either alone or associated with round 
cells) diffusely infiltrated in a reticular structure. 

A few words are required as regards the special tissues of the larynx. 
Sometimes the tubercular process commences in the glanchdce, the de- 
posit of round cells, in the interstices between the acini gradually en- 
croaching on the membrana propria, and leading to the destruction of 
the acinous structure, so that a capsule which in a state of health would 
contain twenty or thirty acini is found holding only four or five of these 
bodies. At last the capsule is destroyed, and there only remain isolated 
portions of degenerate gland structure. The ducts of the glands have 
the greatest power of resistance, and are often found in the tubercular 
infiltration intact with perfect cylindrical epithelium. Tubercular ulcers 
commencing in the glands have been carefully described by Rindfleisch, 1 
who observes that they begin at the mouths of the mucous glands, and in 
appearance are circular, and flat or funnel shaped, with narrow but ex- 
tremely yellow borders. On section of the arteries, a mass of round cells 
is often found partly outside the adventitia, but for the most part amidst 
its fibres. Sometimes there is an abundance of tubercles, some recent 
and some of old date, showing signs of caseation. In these cases the ad- 
ventitia is generally destroyed, whilst the muscularis and intima of the 
arteries almost always remain intact. The muscularis of the veins is, 
however, much more easily destroyed, and the lumen of the vessels un- 

1 Lehrb. d. Path. Gewebelehre, iv. Aufl., 1875, p. 325. 






LARYNGEAL PHTHISIS. 277. 

dergoes great modification and contractions. The capillaries show the 
same power of resistance as the arteries, their endothelial cells generally 
remaining unchanged, and their walls of normal strength. The capillaries 
are often found in excess between the tubercular deposit and the lower 
layer of the superjacent epithelial cells. Tubercle is very seldom de- 
tected within the muscular structures, but Frankel ' found the contractile 
substance, the perimysium internum and corpuscles in a state of fatty de- 
generation. He states that the muscle-corpuscles were increased either 
in number or size in all the muscles he examined. Heinze rarely met 
with changes in the muscular structure, but in two cases tubercles were 
present. Once a small fresh tubercle was found between the fasciculi, 
and once the deposit was in such abundance that only the section of two 
or three separated fibres remained in the midst of the tubercle. In a few 
cases Heinze found the muscle-corpuscles increased in number. It may be 
stated that these changes in the structure of the muscles are the results 
of chronic nutritive deviations, and not specially characteristic of the tu- 
bercular process. 

Diagnosis. — Where the characteristic semi-solid pyriform swellings 
of the ary-epiglottic folds are present it is almost impossible to mistake 
the disease ; but where the thickening is not of such a defined character 
the diagnosis is not quite clear. The examination of the lungs will some- 
times confirm a doubtful diagnosis, and where auscultation yields nega- 
tive results, a careful search should be made in the sputa for the elastic 
tissue of the lung. 

The conditions which are most likely to give rise to an error are 
chronic laryngitis, chronic oedema, and syphilitic thickening or ulceration. 
In chronic laryngitis the swelling is generally much less than in laryngeal 
phthisis, whilst there is more hyperemia ; in oedema the much greater 
transparency of the swelling differentiates it from phthisis, though it must 
be admitted that in advanced laryngeal phthisis oedema is usually added 
to the tubercular infiltration. 

In syphilis the thickening is very irregular, and the ulcers are gener- 
ally large and solitary, and hence frequently unilateral ; they are also 
commonly surrounded by an inflamed areola. In phthisis, on the other 
hand, the swelling is more, smooth and uniform, whilst the ulcers are small, 
numerous, scattered, and situated on a pale ground. The two diseases 
differ also as to the parts they attack. Thus, when syphilis assails the 
epiglottis, it is the lingual surface and free edge which generally suffer ; 
whilst in tubercular ulceration, though the free edge of the epiglottis is 
often attacked, it is the under surface and base which are more generally 
and more deeply affected. In both diseases the whole valve may be eaten 
away, but this result is seen far more often in syphilis than in phthisis. 
Ulceration over the arytenoid cartilages is comparatively rare in syphilis, 
but very common in tuberculosis, and the same observation is applicable 
to the ventricular bands and the anterior commissure of the vocal cords. 
Both diseases attack the vocal cords very frequently, but while phthisis 
generally affects both vocal cords, in syphilis one cord alone is not uncom- 
monly ulcerated. 

The ulcerations in laryngeal phthisis may be extensive, but the actual 
loss of substance which takes place is not generally so great as in tertiary 



1 Ueber pathol. Veranderungen d. KehlkopfmuFculatur bei Phthisikern, Virchow'a 
Archiv, 71-7J), 1877. 



278 DISEASES OF THE PHAIIYNX, LARYNX, AND TRACHEA. 

syphilis. For further observations on differential diagnosis, the reader 
is referred to the article on Syphilis, page 263. 

Catarrhal ulcerations are nearly always very superficial, so that they 
have more the character of erosions, and are most common on the vocal 
cords. Non-tubercular ulceration may, of course, supervene in a person 
suffering from pulmonary phthisis, and such ulcerations may afterward be- 
come tubercular through the deposit of tubercles. 

Prognosis. — The prognosis of laryngeal phthisis is always extremely 
unfavorable, and it is not certain that any cases ever recover. Of all the 
cases of laryngeal phthisis that I have ever seen, I only know of four in 
which I have reason to believe that the disease was entirely arrested. In 
these instances — in all of which there was deposit in the lungs, and in one 
a cavity — the laryngeal signs of the disease disappeared, whilst those ap- 
pertaining to the lungs remained stationary and retrograded. In consid- 
ering the probable duration of life, the age and family history of the pa- 
tient, the character and stage of the lung disease, the amount and kind 
of expectoration, the frequency of the pulse, the temperature of the body, 
the rate at which loss of weight takes place, are the main criteria. These 
various matters are discussed in detail in the text-books of medicine, and 
in monographs on phthisis, and it need only be remarked here that, as a 
rule, patients from eighteen to twenty-five years of age succumb most 
quickly, and that where there is a strong family predisposition to tuber- 
culosis the fatal issue is sooner reached. Disease within the larynx is less 
rapidly fatal than when the morbid process attacks its outer portions; in 
other w T ords, if the epiglottis, or ary-epiglottic folds are infiltrated or ulcer- 
ated the disease terminates more quickly than when the ventricular bands 
or vocal cords are the seat of the disease. This is accounted for by the fact 
that ulceration of the more exposed portions of the larynx interferes most 
with the act of deglutition, and hence favors marasmus. C ceteris paribus r 
the greater the amount of infiltration the more unfavorable the progno- 
sis ; and in cases in which there are numerous scattered ulcers, without 
much thickening of the mucous membrane, the progress is slower than 
where there is general infiltration. 

The following is the duration of life (in months) after the throat- 
symptoms had begun to be troublesome in 100 cases subjected to post- 
mortem examination. It will be seen that in the greatest number of 
cases death occurred in from twelve to eighteen months, and that 66 per 
cent, occurred between six months and two years. Further, it is to be 
observed that very few patients lived more than two years and a half, and 
very few died before six months: 

Table G. 
Duration of IJfe after Throat-sijmptoms had become Troublesome. 



No. of Cases. 
Duration of Life in Months. 

1 49 

2 42 to 48 

4 36 to 42 

5 30 to 36 

13 24 to 30 



No. of Cases. 
Duration of Life in Months. 

19 18 to 24 

30 12 to 18 

17 6 to 12 

4 3 to 6 

5 under 3 



Treatment. — The constitutional treatment must be the same as that 
commonly employed in tubercular disease of the lungs. As regards local 



LAKYNGEAL PHTHISIS. 279 

remedies, the plan already recommended for chronic laryngitis sometimes 
gives relief — the application of mineral astringents, by diminishing the ir- 
ritability of the mucous membrane, often quieting the cough. Of these 
I have found perchloride of iron ( 3 j. ad 3 j.) the most serviceable. In 
the early stages, Dr. Porter 1 has observed excellent results from local 
applications of a solution of sulphate of iron and ammonia. In some 
cases soothing inhalations of benzoin or hop act very beneficially. When 
the cough, however, becomes very troublesome, no treatment gives so 
much relief as the insufflation of morphia. One-eighth of a grain diluted 
with starch should be blown down twice a day, and as the disease ad- 
vances the dose should be increased to one-fourth or one-half a grain. 
It is important to get the larynx, as far as possible, cleared of the masses 
of mucus which often cover it, before the powder is introduced; and the 
patient should endeavor not to cough for a few minutes after the applica- 
tion has been made. This treatment relieves the cough, and generally 
removes the distressing odynphagia, which, by preventing the patient tak- 
ing a proper amount of food, hurries on the fatal issue. The fact that 
the maximum local anaesthesia is obtained in rather less than an hour fur- 
nishes the indication for the time of administration of the powder in ref- 
erence to taking food. When there is much oedema, scarification affords 
relief. These are the simple measures which, after trying many plans of 
treatment, I have been induced to adopt. Other physicians, however, have 
recommended various procedures, some of which may be here referred to. 
Thus Dr. Schnitzler 2 advises insufflation of nitrate of silver, or acetate of 
lead diluted with sugar of milk ; whilst Dr. Marcet 3 recommends, as a 
local application, a solution of iodine in olive oil — twenty grains of iodine 
with five grains of iodide of potassium in an ounce of oil, and further ad- 
vises that this iodized oil should be rubbed into the skin of the neck over 
the larynx. Dr. Marcet also advises scarification " in the swollen and in- 
durated form of laryngeal phthisis." Believing that the tubercular pro- 
cess originates in a high-state of local vascularity, which is " followed by 
an abnormal function residing in the tissue and exerted upon the blood," he 
considers " that by the puncture of the inflamed part, and the consequent 
relief of the vessels, fresh blood is admitted into the capillaries, and the 
normal vital force of the tissue is again called into action." In this way 
he supposes that the morbid process may be temporarily arrested ; though, 
of course, the primary deposit may continue as a cause of irritation and in- 
flammation. When, however, the mucous membrane is extensively infil- 
trated with tubercular deposit, Dr. Marcet thinks that scarification should 
be withheld. Dr. Krishaber 4 considers that cauterization with Vienna 
paste of the outside of the neck just over the thyroid cartilages, has of- 
ten been productive of the best results. He directs that the wound should 
be kept in a state of suppuration for one or more months. 

Where the patient can swallow to a slight extent, but experiences dif- 
ficulty from food occasionally entering the larynx, he should be directed 
to take thickened liquids. A little arrowroot, corn flour, or isinglass, may 
be used for giving a proper consistence to the fluids. By thickening the 
drink it will be much less likely to pass beneath the edges of the epiglot- 
tis into the larynx. It is also well to direct the patient to take the drink 

1 Tubercular Laryngitis, Trans. Missouri State Med, Assn., 1878. 
8 Ueber Kehlkopi'geschwiire, "Wien. Med. Presse, No. 14, u. f. 18(58. 

3 Clinical Notes on Diseases of the Larynx. London, 1801), pp. 94 and 135. 

4 Loc. cit. p. 07:;. 



280 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

at a draught — not to sip it. This mode of procedure makes the act of deg- 
lutition continuous, instead of intermittent, and under these circumstances 
the passage of food into the larynx is much less likely to occur. When 
the patient is unable to swallow at all, life may be often prolonged by 
feeding him with the oesophageal tube. As already pointed out, the dys- 
phagia at this stage of the disease is generally due to the act of degluti- 
tion being imperfectly performed from non-closure of the larynx by the 
epiglottis, not to obstruction in the food-tract caused by the thickened 
epiglottis and arytenoid cartilages. It is from food " going the wrong 
way,'' not from the fact of its being prevented passing down the gullet, 
that the difficulty in swallowing arises. Hence there is generally very 
little difficulty in introducing the oesophageal tube. (See (Esophageal In- 
struments.) The fatal termination of phthisis is, of course, much accel- 
erated if the supply of food is to a great extent cut off, and I may observe 
that I have prolonged life for many weeks by giving food and stimulants 
in the w 7 ay described. Alcoholic liquids, which the irritability of the throat 
would not allow to pass, can be readily introduced into the system by this 
method. Nutritive enemata.can be employed instead of the oesophageal 
tube, but the results of this method are less satisfactory. 

If there is much d}'spncea tracheotomy should be performed, but the 
effect of the operation is, as a rule, only to prolong a miserable existence. 
I cannot recommend the operation as in any sense curative, and quite agree 
with Dr. Solis Cohen, who remarks 1 that "it cannot be curative, either 
directly or indirectly, and is only justifiable to ward off asphyxia from 
oedema, tumefaction, or impaction of necrosed cartilage." It is true that 
cases have been published by Dr. Serkowski 2 and Dr. Ripley 3 which are 
opposed to this view, but I cannot accept these cases as establishing tra- 
cheotomy as a curative operation in laryngeal phthisis. In one of Ser- 
kowski's cases the patient survived the operation three years, and after 
death the lungs showed evidence of far advanced phthisis, but it is highly 
probable that the tubercular affection was developed long after the trachea 
had been opened; and in his other case there is no proof that the patient 
was really suffering from laryngeal phthisis. In Dr. Ripley's case the op- 
eration certainly prolonged the patient's life, but was in no sense curative. 
In opposing tracheotomy in laryngeal phthisis, except when there is ur- 
gent dyspnoea, I differ entirely from my accomplished pupil Dr. Beverley 
Robinson, who observes that in order "to obtain these latter (t. e., favor- 
able results) it seems indicated not to delay the operation, but rather to 
perform it so soon as the nature of the disease is obvious, and other means 
appear of no avail." During the last twenty years I have performed tra- 
cheotomy in a few cases of laryngeal phthisis — perhaps a dozen— but, al- 
though it has often relieved urgent dyspnoea, I cannot recall a single in- 
stance in which the operation delayed the pathological process. Far from 
giving rest to the larynx, the wearing of a canula, in my opinion, tends to 
irritate the windpipe. 



1 Diseases of the Throat. 2d edition. New York, 1879, p. 516. 

2 Allgera. Med. Chi. Zeitung, Aug. 1878. 

3 Beverley Robinson : Op. cit. 



PEKIC1I0ND1UTIS OF THE LARYNX. 281 



PERICHONDRITIS OF THE LARYNX AND NECROSIS OF 

THE CARTILAGES. 

.Latin Eq. — Perichondritis laryngea et Necrosis cartilaginum. 
French Eq. — Perichondrite laryngee et Necrose des cartilages. 
German Eq. — Entziindung des Perichondriums des Kehlkopfs und Ne- 
crose des Knorpels. 
Italian Eq. — Pericondrite della laringee. Necrosi delle cartilagini. 

Definition. — Inflammation of the perichondrium of the larynx, and ne- 
crosis (or, more strictly speaking, caries) of the cartilages, the latter being 
generally dependent on the former. In slight cases the morbid process is 
no doubt often arrested, slight enlargement of the cartilage remaining, 
whilst in syphilis extrusion of a part or whole of the affected cartilage 
may take place ; in other cases, however, when an abscess forms, hectic 
fever almost invariably supervenes and death follows. 

History. — This affection was first described by Hormann ' in 1791, and 
Albers, 2 gave a somewhat fuller account of the disease fifty years later, 
but Ruble first described it in detail. Dittrich, 3 Pitha, 4 and Wilks 5 sub- 
sequently reported cases, but it was only when diseases of the larynx be- 
gan to be investigated with the laryngoscope that any considerable atten- 
tion was devoted to the subject. Since then cases have been published 
by Tiirck, 6 Retslag, 7 Scheck, 8 Gerhardt, 9 Schroetter, 10 myself, 11 and the 
subject has been treated by Ziemssen ia with his usual ability. 

Etiology. — The disease is most common between the ages of twenty 
and forty, and the fact that it occurs very frequently as a sequel to laryn- 
geal phthisis accounts for the greater incidence of the affection at that 
period of life. I have notes of its occurrence in forty-five autopsies; but 
I have met with it during life in many other cases, especially in phthisis 
and syphilis. Men are more subject to the disease than women, and in 
the forty-five autopsies thirty-three of the subjects were males and twelve 
females. The following table gives some information as regards the ages 
of the patients: 

1 Von einer in Vereiterung iibergehenden Halsentziindung Saramlung auserlesener 
Abhandlungen, Leipzig, 175)1. Ryland has been referred to by some authors as having 
mentioned the subject of the disease of the cartilages of the larynx, but he only de- 
scribes one case in which dysphagia was said to occur from premature ossification of 
the cricoid and arytenoid cartilages. 

2 Einige Krankheiten der Kehlkopf sknorpel, Griife und \Valther's Journal d. Chirurg. 
und Augenhlk. , xxix. 1840. 

3 Prag. Viertelj., iii. 1850. 

4 Ibid., Bd. i., 1857. 

B Trans. Path. Soc, 1858. 

8 Wien. Mediz. Zeit.. 18G1, No. 50, and 1863, No. 9. 

7 Ueber Perichondritis Laryngea, Dissertatio, Berlin. 
u Intelligenzblatt, 1872, No. 23. 

9 Archiv f . Klin. Med. , Bd. xi. p. 24. 

10 Loc. cit , 1871. 

11 Trans. Path. Soc, vol. xxii. 

12 Cyclop, of the Prac. of Med., vol. vii. p. 814. 



From 10 to 20 years. . 


. 


" 20 to 30 " . . 


. 1G 


" 30 to 40 " . . 


. 11 



282 DISEASES OF THE PIIAKYNX, LAUYNX, AND TRACHEA. 

Forty-five Autopsies, 

In which JYecrosis of the Cart Hayes was iiresent. 

Ages. 

From 40 to 50 years .... 9 

" 50 to GO " 5 

" GOto 70 " 4 

In three non-fatal cases the disease affected the upper part of the alae- 
of the thyroid cartilage (two the right plate and one the left plate), 
and there were small external abscesses in the neck. I have also seen the 
disease during life in four cases of cut-throat. In the forty-five autop- 
sies (see Pathology, page 284), nineteen occurred in laryngeal phthisis, 
ten in carcinoma, six in tertiary syphilis, four in typhoid fever, two in 
chronic laryngitis, and three were examples of primary chondritis. These 
cases of primary inflammation of the cartilage all occurred in patients over 
sixty years of age; two were men and one a woman. One of them suf- 
fered from gout in the hand. My statistics, however, are not at all relia- 
ble as regards the relative frequency of perichondritis in different affec- 
tions, for whilst I see many cases of phthisis, cancer, and syphilis of the 
larynx, I scarcely ever meet with typhoid fever; indeed, all the cases of 
that disease in which I found disease of the cartilage came under my no- 
tice formerly at the time that I was physician to the London Hospital. 
Retslag's statistics are based on post-mortem examinations at the Patholo- 
gical Anatomical Institution at Berlin, and are of more value for illustrat- 
ing the proportionate frequency of the primary diseases. In his experi- 
ence, out of twenty cases of perichondritis, tuberculosis was the cause ten 
times, typhoid fever eight times, suppurative pleurisy once, and myelitis 
once. As a primary phenomenon the disease is very rare. But in addi- 
tion to the cases which have occurred in my own practice, Turck 1 and 
Schroetter 2 have recorded examples. Rauchfuss 3 has also reported a case- 
in a child three years old. 

The idea of Dittrich 4 that the disease arises from ossification of the 
cricoid cartilage, leading to pressure of the soft parts against the verte- 
bral column and subsequent perichondritis, is probably erroneous. In the 
three cases of disease of one of the alae of the thyroid cartilage the 
patients were all markedly scrofulous, and I believe in these instances 
that the abscesses in the neck led to exposure of the cartilage and ulti- 
mately to its necrosis. 

Syinptoms. — The symptoms of primary chondritis are more marked 
than those of secondary inflammation of the cartilage. Dull aching 
pain, sometimes felt in the larynx and sometimes in the pharynx, with 
difficulty of swallowing, was present in each of my three cases, and after 
the abscess burst, the breath was very fetid. It must be borne in mind 
that in my cases it was the cricoid cartilage which suffered in every in- 
stance. In the secondary disease there is generally so much oedema that 
it is impossible to be certain as to the condition of the cartilages during 
life. The tumefaction in these cases usually even masks the ulceration 
which is almost invariably present. If, however, an ulcer be visible, a 



1 Klinik, etc., p. 207 et seq. 2 Loc cit. 

3 Loc. cit. p. 243. 4 Loc. cit. 



PEPwICIIONDKITIS OF THE LARYNX. 



283 




probe will generally detect the broken-down cartilage. Occasionally 
acute perichondritis is followed by general emphysema, and examples of 
this accident are recorded by both Wilks and Ziemssen. The symptoms 
vary according to the cartilage affected. A necrosed arytenoid cartilage 
can, indeed, sometimes be seen through the ulcerated mucous membrane, 
but when it has been expectorated its absence is not always apparent. 
In the annexed cut (Fig. 83) the appearance of the ary-epiglottic fold is 
shown after the left arytenoid cartilage had been 
expectorated. Even partial destruction of this 
cartilage generally causes complete immobility 
of the corresponding vocal cord, probably by 
giving rise to anchylosis. Necrosis of the pos- 
terior plate of the cricoid cartilage, according to 
its extent, gives rise to paralysis of one or both 
of the posterior abductors of the cords. In my 
three cases of primary chondritis, the mucous 
membrane over the arytenoid cartilage and the 
upper part of the cricoid cartilage was observed 
to be constantly covered with pus, but in no instance was the opening 
of the abscess seen during life, probably owing to its orifice being on 
a posterior surface of the cricoid cartilage. The symptoms of necrosis 
of the thyroid cartilage depend on whether the disease be intra- or 
extra-laryngeal. I do not think that internal disease of the thyroid 
cartilage can be diagnosed with certaintv. In the two cases that I 
have met with, the necrosis affected the inter-thyroid plate, and was 
only discovered after death. When the disease communicates externally 
witti the neck, the necrosed cartilage can be easily felt with a probe. In 
two of my three cases I was able to inject milk into the larynx through 
the fistulous track. In a similar instance Professor Ziemssen also suc- 
ceeded in injecting a colored fluid, and Schroetter passed a probe through 
the fistula into the larynx, which became visible in the laryngeal mirror. 
The following- statement shows the number of times each cartilasre was 
affected in various diseases: 



Fig. 83. — Perichondritis : Lar- 
yngoscopy Appearance after Ex- 
pectoration of Right Arytenoid 
Cartilage. 



Necrosis of the Cartilages ix Forty-five Autopsies. 

Cricoid, in laryngeal phthisis (0 alone, -I with arytenoid) 10 

" syphilis 1 

" cancer 3 

" typhoid 4 

" primarv 3 

— 21 
Arytenoid, in laryngeal phthisis (11 alone, 4 with cricoid) 11 

syphilis (4 times 1 cartilage, once both cartilages) 5 

" cancer G 

chronic laryngitis (lungs healthy) 2 

— 24 
Thyroid, in laryngeal phthisis 'I 

" cancer 1 

— 3 



Diagnosis. — Primary chondritis or primarv inflammation of the in- 
vesting membrane may be suspected in the earlier stages of the disease 



284 DISEASES OF THE PHARYNX, LARYNX. AND TRACHEA. 

when there is a dull, aching, or boring pain, with enlargement of some 
portion of the framework of the larynx, but without much hyperaemia of 
the mucous membrane. At a later period the soft tissues generally be- 
come involved, and the action of one or both the vocal cords impaired. 
There is also often a fetid discharge. In secondary inflammation of the 
perichondrium its condition is often masked by the swelling of the mu- 
cosa and submucosa, but perichondritis may be surmised if, in the absence 
of cicatricial contractions, there is much distortion of any part of the la- 
rynx. When there is deep ulceration a probe can very often be passed 
through the opening, and the necrosed cartilage at once recognized. 

Pathology. — In secondary inflammation of the cartilages, which, as 
already shown, is much the most common form, the morbid process 
almost always commences in the perichondrium. The fibrous invest- 
ment of the cartilages becomes thickened, its individual fibres are sepa- 
rated and enlarged, and pus forms between them. At a later period a 
purulent collection takes places beneath the membrane, which thus be- 
comes separated from the cartilage, and the latter, deprived of its vascu- 
lar supply, undergoes molecular death. The affected cartilage is often of 
a dark gray, or even black color. The presence or absence of discolora- 
tion seems to depend on whether there is communication, through ulcer- 
ation of the tissues, between the cartilage and the atmosphere. Where 
this communication does exist, as is most frequently the case, the surface, 
and sometimes even the entire thickness of the cartilage, is discolored. 
On microscopic examination at the earliest stages the cartilage corpuscles 
are found to be broken down, and they ultimately disappear by a process 
of fatty degeneration. The intercellular substance first becomes thick- 
ened and opaque, and subsequently undergoes a retrograde metamor- 
phosis of the fibres into purulent matter. Occasionally the cartilages 
appear to undergo a kind of molecular absorption, and then seem greatly 
atrophied. An example of this condition is figured by Riihle. 1 In sec- 
ondary inflammation of the cartilages the tissues around the perichon- 
drium are always greatly swollen and saturated with pus or serum. 

Prognosis. — The prognosis is very unfavorable as regards life, except 
in very slight cases, in those of traumatic origin, or where syphilis is the 
cause of the disease. In the latter case, although the morbid process may 
be arrested after tracheotomy has been performed, contraction of the la- 
ryngeal canal generally takes place, and this affection, though it can be 
palliated, is seldom cured. 

Treatment. — In the acute stage of the disease little can be done in 
the way of treatment, except to relieve, as far as possible, the hyperaemia 
or oedema of the superjacent tissues. The former condition is met by 
the usual warm soothing inhalations, the latter by scarification. Should 
primary disease of the cartilages be diagnosed, two or three leeches 
should .be applied to the neck, as nearly as possible over the seat of the 
affected cartilage, and repeated every other day, until either some bene- 
ficial effect is produced or the treatment appears useless. Tracheotomv 
often becomes necessary, and even in phthisis the patient's life may be 
prolonged by the operation. Where the posterior plate of the cricoid 
cartilage is the seat of the disease, the patient may be fed by means of 
the oesophageal tube ; in one of my cases the patient, who was quite un- 
able to swallow a drop of fluid, was kept in a state of perfect nutrition 
for nine weeks by this mode of feeding. 

1 Loc. cit. p. 1. 



PERICHONDRITIS OF THE LARYNX. 285 

In cases of syphilis and cut-throat, or in any condition where the 
inflammatory process is arrested, dilatation of the contracted laryngeal 
passage may be subsequently effected, and there are various mechanical 
measures which may be resorted to. Since the year 18G2 I have used an 
instrument for this purpose (see page 192), but must confess that the 
results have been disappointing. The thickening of the cartilages, and 
in some cases the collapse of the cartilaginous framework from the fall- 
ing inward of its walls, the density of the cicatrized tissues in syphilis, 
and the constant tendency which these fibrous structures show to recon- 
tract, render treatment very tedious, and a relapse generally follows as 
soon as mechanical treatment is discontinued. In order to meet the 
many difficulties which these cases present, Professor Schroetter, 1 of 
Vienna, has devised and carried out a method by which he has in many 
cases greatly increased the size of the trachea, and in some instances has 
enabled the patient to dispense altogether with the canula. 3 Dr. Labus, 
of Milan,' has also completely succeeded in one case. 

In the first stage of treatment, Professor Schroetter employs catheters 
and rigid vulcanite tubes of graduated sizes, bent at a convenient angle 
for introduction into the larynx; the latter taper somewhat toward the 
point, so that they can be gradually worked into the stricture by the use 
of a moderate amount of force, and being open at both ends breathing is 
not obstructed during the operation. In order to prevent the patient 
from blowing or coughing particles of mucus into the face of the opera- 
tor, a short piece of curved tubing, which can be turned in any direction, 
is fitted to the proximal end of the dilating tube. When the calibre of 
the canal has been increased to about the size of a No. 15 bougie, the 
second stage of treatment commences, and this constitutes, in fact, the 
distinctive feature of Schroetter's method. In order to affect any perma- 
nent dilatation of the stricture, it is requisite that the cicatricial tissue 
should be put on the stretch, or the collajosed cartilages kept apart, for 
several hours daily, and it need scarcely be observed, that on account of 
the irritation which would be set up in the pharynx and the consequent 
nausea, it would be impossible for any patient to retain a large staff in 
his larynx, passing out through the mouth, for more than a few minutes 
at a time. With the view of meeting this difficulty, Schroetter devised 
the plan of using pewter plugs, of various diameters, and about an inch 
and a quarter in length, which being introduced into the larynx are re- 
tained in situby means of the tracheal canula (Fig. 52). As they neither 
interfere with deglutition nor respiration, with a little practice the patient 
becomes able to wear these plugs for the greater part of each day. The 
various circumstances under which this process of dilatation can be car- 
ried out have been well described by Dr. Hack 4 in a recent lecture. 

In some cases dilatation can be effected from below, that is by passing 
plugs up from the tracheal opening. Professor Gerhardt 6 has reported a 
case cured in this way, but I have rarely found it practicable, and never 
permanently successful. 



1 Beitrage zur Behandlung der Larynx Stenosen, Vienna, 1876. 

- Private communication from Professor Schroetter. 

3 II caterismo e la dilatazione meccanica nelle stenosi della laringe, Milano, 1876. 

4 Volkmann's Sammlung Klin. Vortriige, No. 52. 

5 Archiv. fur Klin. Med., Bd. xi. p. 578. 



286 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



LUPUS OF THE LARYNX. 

Latin Eq. — Lupus laryngis. 
French Eq, — Lupus du larynx. 
German Eq. — Lupus des Kehlkopfs. 
Italian Eq. — Lupus della laringe. 

Definition. — Lupus (pathologically, similar to the same disease when 
occupying the skin of the nose) affecting the larynx, either primarily or 
secondarily. 

Etiology ', etc.— Lupus of the larynx is a rare disease, and but few 
authors make any mention of it whatever. Tiirck, 1 however, has met 
with five cases, Tobold 2 with two cases, and Ziemssen, 3 Grossman, 4 and 
Lefferts, 5 have each reported one case. The last-named author believes, 
indeed, that the malady, if sought for in cases of cutaneous lupus, would 
probably be more frequently found than is generally supposed. I have 
myself met with only two examples, which are hereafter reported (p. 287 
et seq.). The causes of the affection are not better known than those of 
ordinary lupus, with which it is identical except in site, but it probably 
originates in some constitutional defect which is either of the same nature 
as scrofula or closely allied to it. 

Symptoms. — The subjective phenomena of lupus of the larynx are in 
no way characteristic; in the early stages the patient generally complains, 
as in many other affections of this part, of slight sore throat and difficulty 
of swallowing, whilst, if the disease advances, there is often considerable 
dyspnoea. There is usually some hoarseness, and occasionally complete 
aphonia. Very frequently lupus is observed at the same time on some 
part of the face. On laryngoscopic examination the morbid appearances 
are marked, but still not of so peculiar a kind as to enable the observer at 
once to recognize the disease: for it offers some points of resemblance to 
syphilis, cancer, and phthisis, and these three affections must therefore be 
excluded by a careful investigation of the general condition and history 
of the patient. In Tiirck's cases there were ulcers on the epiglottis with 
loss of substance, chiefly in the form of a heart-shaped piece eaten out of 
the middle, as in my case here appended. In several instances growths 
have been noticed on the anterior surface of the. posterior wall of the la- 
rynx. These appear as fleshy elevations of variable size, some of which 
have an irregular, jagged outline, whilst others are almost spherical. In 
Leffert's case the epiglottis was covered with small fleshy tubercles and 
worm-eaten ulcerations, and in one of my cases (Fig. 85) half the valve 
was studded with molluscum-like projections. Sometimes the mucous 
membrane of the pharynx is merely thickened, but the greater part of the 
hard and soft palate and uvula may be covered with reddish fleshy, wart- 
like growths, and the pharynx extensively ulcerated. 



1 Zeitsch. d. Gesellsch. d. Aerzte zu Wien, 1859, No. 11. 

2 Kehlkopfkrankheiten, p. 307. 

3 Cyclopaedia of Med., vol. vii. p. 848. 

4 Wien. Med. Zeitung. 1877, Xo. xx. 

5 American Jour, of Med. Sci., April, 1878. 



LUPUS OF THE LARYNX. 287 

Pathology. — According to Virchow, 1 the usual anatomical condition 
found in lupus of the larynx is presented by the following description of 
a case examined by him: An indurated cicatrix beset by thick knobs as 
large as a pea, extended from the middle of the dorsum of the tongue 
deeply down into its roots. The epiglottis was excessively hard, and was 
bordered bv hard warts. From this part the tissues were hardened in a 
knotty manner as far down as the trachea. The arytenoid cartilages were 
deeply ulcerated, and surrounded by hard papillary outgrowths. Accord- 
ing to the same investigator the lupus nodules are composed of a young 
and soft granulation tissue, which is usually very vascular. It contains 
small round cells, and originates in proliferation of the connective tissue, 
and not of the epithelium. The ultimate tendency of the morbid action 
is toward destructive ulceration, and in apparent healing, instead of a 
healthy and permanent cicatrix being produced, a tissue of low vitality is 
formed which is soon followed by a fresh outbreak of the disease in the 
same spot. 

Diagnosis. — Lupus of the larynx is easily recognized when the charac- 
teristic skin affection is also present. In young subjects, also, there is not 
likely to be much difficulty in deciding as to the nature of the disease, ex- 
cept in cases of hereditary syphilis. When the laryngeal malady consti- 
tutes the only local manifestation of the disease, a careful investigation of 
the history and general condition of the patient must be made before ar- 
riving at a conclusion; if the question of syphilis arises, it will soon be 
settled by the administration of iodide of potassium. 

Prognosis. — The generally intractable nature of lupous ulceration of 
the face is well known. . Once established, the disease may last for the 
lifetime of the patient, entirely unrestrained by any means, surgical or 
therapeutic, that may be adopted for its cure. In the larynx, lupus does 
not usually appear to be a very dangerous affection, but occasionally the 
new formation is so abundant as to block up the glottis and necessitate 
tracheotomy, or the continued impediment to respiration may make a se- 
rious inroad on the constitution of the patient. The progress of disease 
in the larynx, however, appears, as a rule, to be very slow, and the malady 
is occasionally arrested. 

Treatment. — Internally cod-liver oil should be administered, and, if the 
disease is active, its progress may sometimes be arrested by caustic appli- 
cations. The solid nitrate of silver is the best remedy that can be em- 
ployed for this purpose, but its effects should be carefully watched, and 
too extensive a cauterization of the diseased surface at one time should 
be carefully avoided. It may here be mentioned, however, that in Dr. 
Leffert's case, caustics were so badly borne that he was obliged to resort 
to " much milder treatment, in which a modified Lugol's solution and sed- 
ative applications played an important part, to the great comfort of the 
patient, but without amelioration of the local pathological changes." 



CASES ILLUSTRATING LUPUS OF THE LARYNX. 

In March, 1869, I was requested by my colleague, Mr. Cooper, at the 
London Hospital, to see Thomas P., aged fourteen, on account of difficulty 
of swallowing. I found him suffering from destructive ulceration of the 
alse of the nose, and from thickening and extensive ulceration of the lips. 



Die krankhaften Geschwiilste, Bd. ii. p. 490. 



288 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

Between the nose and the mouth there was a dense white cicatricial tissue. 
The history of the case was that the nose became swollen nine years pre- 
viously, and that after a fortnight ulceration appeared, which rapidly de- 
stroyed a portion of that organ and spread down to the lips. The patient 
stated that he had been in Guy's Hospital on several occasions, and that 
nitric acid had been applied Under chloroform five times. This treatment 
resulted in healing of the tissues between the nose and the lips, but he 
had still an open ulcer involving the right ala of the nose and the septum, 
and nearly the whole of the superior margin of the upper lip, and for this 
he had applied to the London Hospital. The patient had a thick and 
slightly nasal voice, and complained that in swallowing "things often 
went the wrong way." A careful examination was made with a view of 
discovering any trace of syphilis or phthisis, but the lungs were perfectly 
healthy, and Mr. Cooper informed me that iodide of potassium had pro- 
duced no effect whatever. The pharynx and posterior nares were seen to 
be healthy, but on laryngoscopic examination the epiglottis was found to 
be generally thickened, and to be ulcerated in the centre and along its free 
edge; the ary-epiglottic folds were also slightly swollen (Fig. 84). There 
was nothing at all characteristic of lupus about the epiglottis, and had the 
patient not been suffering from lupus of the face, I should certainly have 
attributed the laryngeal affection to tertiary syphilis. In view, however, 
of the facial phenomena, I felt no doubt that the thickening of the epi- 





FlG. 84. — Lnpus of the Larynx, Fig. 85. — Lupus of the Larynx, show- 

showing Thickening and Ulceration ing Molluscum-like Growths on the Epi- 

of the Epiglottis. glottis. 

glottis was due to lupus. I saw the patient two years later, and found 
that under Mr. Cooper's treatment, consisting principal^ of the local ap- 
plications of strong nitric acid, and the internal use of cod-liver oil, the 
cutaneous ulcerations had ceased except at the left side of the mouth, 
where there was still a small ulcer. The larynx was in the same condition 
as when I first saw it, the ulcer neither having healed nor increased. 

Elizabeth B., a native of Cork, aged eighteen, applied to me in June, 
1877, on account of difficulty in swallowing and slight hoarseness. The 
whole of the left side of the nose to the inner canthus of the left eye had 
been destroyed by ulceration which had lasted six years, but had now 
healed up except at the cartilaginous portion of the septum. The patient 
stated that some years previously, in one of the Dublin hospitals, a 
strong acid had been applied to her face, and had done her a great deal 
of good. On examining the throat, the uvula was found to be greatly 
thickened and elongated, measuring, as nearly as possible, two centimetres, 
both in length and breadth; the posterior pillars of the fauces were so 
much thickened that they were each about as broad as a man's thumb, 
leaving only a narrow space (about half a centimetre) of the posterior 
wall of the pharynx visible. On making a laryngoscopic examination, 
the epiglottis was seen to be enlarged, pendent, and immobile, its right 
side being covered with molluscum-like growths, and its centre occupied 
by a smooth and slightly depressed cicatrix (Fig. 85). Owing to the 



LEPROSY OF THE LARYNX. 289 

general tumefaction, only a portion of the arytenoid cartilages could be 
seen; the mucous membrane over them was slightly swollen. This patient 
was treated by large doses of iodide of potassium and insufflation of bis- 
muth powder for six weeks without any effect; she subsequently remained 
under observation for seven months, during which time various local rem- 
edies were used, but without my being able to notice any change in the 
pharynx or larynx. 



LEPROSY OF THE LARYNX. 

(Synonym : Elephantiasis Gr^ecorum.) 

Latin Eq. — Lepras vera? laryngis. 
French Eq. — Lepre du larynx. 
German Eq. — Aussatz des Kehlkopfs. 
Italian Eq. — Lepra della laringe. 

Definition. — An infiltration of the laryngeal structures by a tubercular 
granulation-tissue, generally leading to destructive ulceration of the part. 
The disease occurs only as a concomitant of general leprosy. 

Symptoms. — The investigations of Virchow ! have shown that even in 
the middle ages hoarseness and dyspnoea were so generally regarded as 
the signs of leprosy, that the possession of a " vox rauca " was almost 
sufficient to cause an individual so afflicted to be stigmatized as a leper. 
Since the introdution of the laryngoscope several practitioners who have 
met with general leprosy have endeavored to ascertain the condition of 
the larynx by actual inspection. Amongst these Wolff, 3 Gibb, 3 Schroetter, 4 
and Elsberg 5 have furnished us with the most systematic observations, 
and I am now able to add three cases. Wolff, at Madeira, found chronic 
catarrh of the larynx, with considerable swelling, and vascularity of the 
epiglottis. The mucous membrane of the arytenoid cartilages and the 
ventricular bands was of a dark bluish red color, much thickened and ap- 
parently loosened from the submucous tissue. The vocal cords were 
thickened, and of a yellowish red hue. In addition, small papillary growths 
were present in different parts of the larynx, but rarely on the vocal cords. 
At the same time muscular pareses, interfering with phonation and res- 
piration, could be detected by the laryngoscope. In Gibb's case there 
was great loss of substance of the epiglottis and vocal cords, together 
with a large amount of thickening of the other parts of the larynx. 
Schroetter found isolated tubercles, or uniform thickening of the various 
tissues of the larynx. In some cases laryngeal stenosis was developed 
to such an extent that the calibre of the canal was reduced to the diameter 
of an ordinary lead pencil. In Elsberg's cases the epiglottis was enor- 
mously thickened and covered with tuberous masses, whilst smaller growths 
occupied the ary-epiglottic folds. In my cases there was generally thick- 



1 Die krankhaften Geschwiilste, Bd. ii. p. 519. 

2 Virchow's Archiv, Bd. xxvi. p. 44, 18G3. 

3 Diseases of the Throat, p. 272, London, 1864. 

4 Laryngologisehe Mittheiluneren. ii. p. 84, 1874. 

4 Elsberg and llice : New York Med. Record, vol. xv. No. 1. 

19 



290 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

ening of the epiglottis, and in one instance there was considerable oedema 
of the valve, and two small ulcers near its centre (Fig. 8G), but in no in- 
stance did I meet with distinct tubercles. 

Pathology. — According to Virchow ' the pathological process, in lep- 
rosy of the larynx consists in a development of tuberculous granulations 
on the mucous membrane, which are scarcely distinguishable from syphili- 
tic condylomata or follicular abscesses. They possess, however, much 
more hardness and vascularity. In some cases tubercles are not present, 
but a grayish white non-ulcerating infiltration of the mucosa and sub- 
mucosa. The tendency is toward ulceration, but the course of the dis- 
ease is so extremely slow that in some cases, though progressive, it never 
attains this stage. 2 In Virchow's cases the base of the ulcerations was 
formed by indurated tendinous tissue, which penetrate deeply into the 
surrounding structures. The extraneous granulation-tissue bears a close 
resemblance to the new formations of lupus, and consists microscopically 
of simple spindle-shaped and stellate connective-tissue cells. By active 
division of the cells and nuclei the intercellular substance soon becomes 
almost obliterated or absorbed, until all the normal components of the 
part disappear. The morbid cell infiltration has a considerable prolifera- 
tive character, the individual cells being round, pale, slightly granular, 
easily destructible, and usually possessing a rather large granular nucleus 
and a nucleolus. The great majority of these cells are superior in size to 
red blood corpuscles, some attaining the dimensions of the largest mucous 
corpuscles. 

Diagnosis. — The diagnosis of laryngeal lepra is simple, the internal 
malady never occurring except as a concomitant of the more pronounced 
forms of general lepra. 

Prognosis. — The prognosis is unfavorable, the laryngeal phenomena 
often constituting only a small part of an extensive and terrible disease 
of the cutaneous system. 

Treatment. — It would be futile, in the present state of our knowledge, 
to discuss any measures for the radical cure of the disease. The various 
local phenomena must be treated according to the general rules laid down 
in the articles on Chronic Laryngitis and CEdema of the Larynx. If the 
dyspnoea is urgent tracheotomy must be performed. 



CASES ILLUSTRATING LEPROSY OF THE LARYNX. 

George L., aged eighteen, sent to me by Mr. Erasmus Wilson, De- 
cember, 4, 1865. The face of the patient and the soles of his feet are 
covered with small round shining tubercles. The same condition exists 
to a less extent on the palms of the hands. The patient's voice is strongly 
nasal, and the mucous membrane of the nares so thickened that both the 
anterior and posterior nasal passages are nearly completely obstructed. 
The epiglottis is very much thickened, but there are no distinct tubercles 
and no ulceration. There is no difficulty in swallowing. 

H. E., aged twenty-seven, a Norwegian sailor, from Bergen, whose 
ship is in the London Docks, came with his brother (see next case) to the 
London Hospital in February, 18G9, on account of difficulty of breathing 
and swallowing. His forehead and right eyebrow were covered with soft, 

1 Loc. cit. 

2 Thomas: Beitrage z. path. Anat. d. Lepra Arab. Virchow's Archiv, Bd. lvii. p. 
455, 1873. 



FRACTURES AND DISLOCATIONS OF THE LARYNX. 291 

shining, yellowish brown, irregular, but generally round or oval, tumors, 
varying in size from a pea to a marble. The right ear was much swollen 
and of purple color. The pharynx showed 
slight thickening of the right side, especially 
of the right posterior pillar, which projected 
centrally as far as the uvula, and blocked 
up the view of the posterior nares. The 
epiglottis was greatly thickened and cede- 
matous, especially on the left side, and there 
were two small ulcers on the free edge of 
the valve near its centre. There were, how- 
ever, no distinct tubercles. 

A. E., aged tweiltV-five, brother of the Fio. 86.— Leprosy of the Epiglottis, 

last patient, and like him a sailor. Nose and gEStST"* Thickenin e and Sli s ht 
lips swollen, and covered with small round 

shining tubercles. Hair had fallen off eyebrows and beard. Had a hoarse 
voice, but no difficulty of swallowing. Papilla at back of tongue enor- 
mously hypertrophied. Uvula thickened; three small ulcers on the poste- 
rior wall of pharynx. Laryngoscopic appearances: A slightly congested 
and highly succulent condition of the mucous membrane of the larynx. 
No ulceration nor tubercles. 




FRACTURES AND DISLOCATIONS OF THE LARYNX. 

Latin Eq. — Fractune cartilaginum laryngis. Laxatune laryngis. 
French Eq. — Fractures et luxations des cartilages du larynx. 
German Eq. — Fracturen und Verrenkungen der Kehlkopfsknorpel. 
Italian Eq. — Fratture e lussazioni delle cartilagini della laringe. 

Fractures. — These injuries are of unfrequent occurrence, but never- 
theless certain authors have succeeded in collecting a considerable num- 
ber of cases from various sources. 1 In 1868 Henoque 2 published a mono- 
graph based on the consideration of fifty-two cases, which comprised all 
that had previously been recorded by medical writers. It appears that 
the larynx cannot be fractured by concussion unless it is supported to 
some extent on the vertebral column, as when the body is supine — the 
mobility of the organ and the elasticity of its cartilages, when the neck is 
not fixed, preventing a direct blow from producing more than a contusion 
of the soft parts. 3 In garrotting, the larynx is often fractured, not by 
pressure backward against the vertebral column, but by lateral compres- 
sion of the wings of the thyroid cartilage. It is probable that ossification 
of the cartilages renders the larynx more brittle and liable to break under 
the influence of violence. As Dr. Panas judiciously observes, 4 a prema- 



1 See Gurlt : Handbuch der Knochenbriiche, p. 316 ; also Henoque : Gazette heb- 
domad., 18G8, No. 39, 40. 
s Ibid. 

3 See the experiments made by Keiller (Edin. Med. Journ., 18oG, p. 824) ; Cavasse : 
Gazette hebdom. , 1861, p. 372; Helwig: Casper's Vierteijahrschrift, 1861 Bd. xix. p. 
340 ; and Gurlt : Loc. cit. 

4 Annales des Maladies de l'Oreille, etc., Mars, 1878. 



292 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

ture senility, whether produced by alcoholism or otherwise, predisposes the 
cartilages to suffer from the effects of injuries. The thyroid is the carti- 
lage most usually fractured, whilst in those cases where the cricoid suffers, 
the injury is generally more extensive and dangerous. An analysis of 
Henoque's cases, so far as the cause and exact seat are definitely stated, 
shows that 15 resulted from violent manual compression, 2G from falls, 
accidents with machines, and rolling vehicles, 4 from hanging, whilst 5 
occurred in lunatics in some unexplained way through the wearing of the 
straight-waistcoat. In 23 instances the thyroid alone was fractured, in 7 
the cricoid alone, and in 7 both these cartilages, whilst in the remaining 
cases the hyoid bone, larynx, and trachea, all suffered together from a 
common injury. 

Symptoms. — The symptoms of fracture of the larynx vary considera- 
bly according to the extent of the injury done to the cartilages and the 
soft parts connected therewith. I have myself met with only one case: 

The patient was an acrobat, and whilst lying flat on the floor another 
gymnast had jumped on his neck; he had often done this before without 
any bad effect, but on the occasion referred to great pain was felt at the 
time, and soon afterward a feeling of constriction was experienced in the 
throat, and the patient had great difficulty in swallowing. I saw him 
three days after the accident, in July, 1865. There was a vertical frac- 
ture of the thyroid cartilage in the median line. The soft parts over the 
anterior part of the larynx were not at all swollen though slightly ecchy- 
motic. The two alse could be easily made to move on each other, and 
produced distinct crepitation. A laryngoscopic examination showed con- 
siderable oedema and redness of the epiglottis. The patient suffered from 
complete aphonia and great dysphagia. Strips of plaster were applied 
transversely across the thyroid cartilage, and the epiglottis was scarified. 
At the end of a few days the patient was able to swallow well, but the 
hoarseness remained for six weeks; at that time the cartilage had com- 
pletely united, and there was-no trace of a fracture. 

The usual symptoms of fracture of the larynx are dyspnoea, cough, ex- 
pectoration of mucus tinged with blood, and more or less pain and ten- 
derness in the part. Emphysema of the neck is also likely to supervene, 
and in some cases the air may penetrate into the cellular tissue of the 
chest and back, or even further. On manipulation, the broken cartilages 
will crepitate when the fragments are rubbed against each other, whilst 
occasionally over-riding of the fractured edges gives rise to a perceptible 
deformity. 

Prognosis. — Fractures of the larynx are always attended with consid- 
erable risk, as the violence which occasions them is generally great, and 
the injury to the soft tissues profound. To judge from Henoque's cases, 
fracture of the cricoid cartilage is an invariably fatal occurrence, but if 
tracheotomy be promptly performed some of these cases might probably be 
saved. 

Treatment. — Unless the symptoms are very slight it will be advisable 
to perform tracheotomy as soon as possible, otherwise the patient, although 
progressing favorably, is not unlikely to perish suddenly on making some 
slight movement. 1 Hiiter 2 goes so far as to say that " as soon as fracture 



1 See a case reported by Fredet : Quelques considerations sur les fractures trauma- 
tiques du larynx, Paris, 1805, p. 5. 



Pitha und Billroth's Handbuch, Erlangen, 1871, p. 12. 



FRACTURES AND DISLOCATIONS OF THE LARYNX. 293 

of the larynx has been diagnosed tracheotomy should be performed, and 
that even in cases where the diagnosis is not quite certain, the operation 
should nevertheless be carried out. In no case," he observes, " should 
the practitioner wait till a fit of suffocation comes on, as such an attack 
may supervene so very suddenly." If the cartilages are much crushed it 
w T ill perhaps be best to lay open the whole length of the larynx, and en- 
deavor to replace the fragments in their proper position. Dr. Panas ! 
suggests that in some cases where tracheotomy is necessary the fractured 
portions of the laryngeal cartilages maybe kept in proper apposition, and 
the patency of the laryngeal canal preserved, by the introduction of a 
small hollow india-rubber plug into the larynx from the tracheal opening 
and its subsequent inflation. Leeches should be applied to the neck, if 
there is much inflammatory tumefaction; and ice, both externally and in- 
ternally, is sometimes of service. In cases of extreme injury, extirpation 
of the larynx or resection may have a future. 



Dislocations of the Larynx. 

Those luxations which occur between the larynx and hyoid bone will 
be referred to in the next section, and here intra-laryngeal dislocations 
alone will be briefly described. Examples of this condition have been re- 
ported by Sidlo 2 and Stoerk. 3 In Sidlo's case both the arytenoid carti- 
lages were dislocated forward and downward, so that their bodies assumed 
a horizontal position. The dislocation appears to have been the result of 
the contraction of a syphilitic cicatrix on the posterior surface of the cri- 
coid cartilage. In Stoerk's two cases the left arytenoid cartilage was in 
each instance dislocated transversely inward, and there was at the same 
time considerable tumefaction of the affected cartilage. Both patients 
were men whose voices had been of a falsetto character from childhood. 
One case appears to have resulted from cicatricial contraction after diph- 
theria; in the other the etiology was altogether unknown. 

Inversion of one or both the ventricles is another rare form of intra- 
laryngeal dislocation. Of this condition only three illustrations 4 are on 
record, and in only one of these (that of Dr. Lefferts 5 ) was the accident 
recognized during life. In the latter case both ventricles were prolapsed, 
and the left one enormously hypertrophied. The accident appears to have 
happened during sleep, and had occurred twenty years before the patient 
came under Dr. Lefferts's notice. Since the time of its occurrence the 
patient had been hoarse, and latterly there had been considerable dysp- 
noea. Dr. Lefferts cured his patient by performing thyrotomy and extir- 
pating the everted ventricles. 



J Op. cit. p. 4. 

2 Ziemssen's Cyclopaedia, vol. vii. p. 968. 

3 Wiener Med. Wochenschrif't, No. 50, 1878. 

4 Mackenzie : Growths, etc. , p. 34. 

5 New York Med. Record, June 3, 1876. 



294 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



FRACTURE AND DISLOCATION OF THE HYOID BONE. 

Latin Eq. — Fractune et luxaturce ossis hyoides. 
French Eq. — Fractures et luxations de Pos hyoide. 
German Eq. — Fracturen und Verrenkungen des Zungenbeins. 
Italian Eq. — Fratture e lussazioni dell' osso ioide. 

Fracture. — The hyoid bone is occasionally fractured, and several ex- 
amples of this injury are on record. The occurrence, however, is very 
rare, and no practitioner appears to have encountered more than one case. 
Gibb l has treated the subject almost exhaustively in a monograph based 
on the consideration of thirteen examples collected from various sources. 
It appears that the cornua are the only parts of the bone likely to be 
broken, at least in the adult, as in only one of the thirteen cases was the 
body fractured, the patient being a child aged six years. Of the remain- 
ing examples the right cornu was broken in four, and in five the left. In 
one case both the greater cornua were fractured, whilst in two the pre- 
cise nature of the injuries was undetermined. Fracture of the hyoid bone 
is usually caused by forcible manual compression, as in garrotting, hang- 
ing, bowstringing, or by direct violence, as by falls or blows on the neck. 
The bone may also be fractured by excessive action of the muscles of the 
part. 2 

As regards symptoms, there is usually considerable pain in the neck, 
with inability to turn the head. Extreme odynphagia is also commonly 
present. The voice is generally much affected, and the patient can only 
speak with pain and effort, whilst occasionally the injury may produce so 
much narrowing of the glottis as to threaten death by asphyxia. On ex- 
amining the throat the fragments will usually be found to be widely sep- 
arated, and true crepitus is seldom met with. Swelling, ecchymosis, and 
even lacerations of the mucous membrane of the mouth, are present with 
more or less frequency. The following case fairly illustrates the accident: 

In November, 1864, a patient came to the Hospital for Diseases of the 
Throat, suffering from great difficulty of breathing, also from dysphagia 
and great pain in the throat. The man was a bricklayer, and the previous 
day he had fallen about thirty-five feet from the scaffolding of a house. 
He had cut the right side of his face and had greatly contused the right 
shoulder, but he was not aware of any other injury. There was consid- 
erable swelling, and some redness between the angle of the jaw and the 
thyroid cartilage on the right side, and on making a careful examination 
of the neck the right greater cornu of the hyoid bone was evidently sep- 
arated from the body of the bone. The patient was unable to protrude 
his tongue, as it caused so much pain, and no laryngoscopic examination 
could be made. Six leeches were applied over the seat of the injury, but the 
fractured bone could not be " set," as any attempt to manipulate it caused 
very great pain. On the following day the patient was quite unable to 
swallow, and it became necessary to feed him with an oesophageal tube. 



1 On Diseases and Injuries of the Hyoid or Tongue Bone, London, 18G2. See also 
Pitha and Billroth's Archiv, vol. iii.: Fracturen des Kehlkopfs. 
a See Gibb, op. cit. 



FRACTURES AND DISLOCATIONS OF THE HYOID BONE. 295 

This procedure had to be carried out for eleven days, when the patient 
sufficiently recovered his power of swallowing. At the end of a month 
from the time of the accident the fracture was completely united, a super- 
abundant amount of callus having been thrown around the broken ends 
of the bone. 

The treatment of fractures of the hyoid bone is sufficiently obvious on 
perusal of the foregoing case. Local bloodletting is advisable if there is 
much swelling, whilst rest and silence must be strictly enjoined. Seda- 
tives may be given to the patient, and feeding must be carried out, if 
necessary, by an oesophageal tube. If, however, the passage of the tube 
causes much pain, the patient must be fed by nutritive enemata. Should 
svmptoms of asphyxia supervene, tracheotomy must at once be resorted 
to, but scarification of the interior of the larynx may suffice if there is 
only slight oedema. If the local inflammation is great the patient should 
suck ice continually, and ice or cold lotions should be applied to the neck 
externally. 

Dislocation. — This is an occasional occurrence, but as the symptoms 
are not very obvious, the condition is probably often overlooked. Gibb ' 
has collected several cases, some of which came under his own observa- 
tion. The causes of the luxation appear to be most frequently a relaxation 
of the muscles and tissues of the part, which allows of an undue amount 
of motion. The accident may result from a violent strain, but is more 
apt to occur when tumors of the neck encroach laterally on the hyoid 
bone. In several of the examples recorded the dislocation seems to have 
been almost chronic in its character, and liable to continual recurrence 
throughout the whole of the patient's life. 

I have met with three cases of dislocation of the hyoid bone. Two 
of these were caused by the pressure of tumors — one cancerous, the other 
lvmphomatous. The third case occurred in a clergyman who had the 
power of producing the affection whenever he desired, 2 but in whom it 
also often occurred involuntarily. In none of these cases were the local 
symptoms caused by the displacement at all serious. There was no dys- 
phagia, and only slight hoarseness which might have been due to other 
causes. 

Several preparations in anatomical museums illustrate displacement 
of the hyoid bone by tumors of the neck, such as bronchocele, 3 and ma- 
lignant growths of the tongue, 4 pharynx, 5 and oesophagus. 6 In a case 
brought before the Pathological Society 7 and reported on by Gibb, a 
medullary cancer as large as an orange was situated above and to the 
right of the thyroid cartilage, overlapping its right wing. The body of 
the hyoid bone was pushed obliquely to the left side of the thyroid car- 
tilage, its right horn being much displaced upward, whilst its left horn 
rested on the superior border of the thyroid cartilage. 

The dislocation can generally be easily reduced by throwing the head 
backward, relaxing the lower jaw and gently rubbing the displaced bone. 
The parts may be subsequently strengthened by the cold-water douche 



1 Op. cit. 

2 Compare the analogous case of Dr. Ripley, recorded by Gibb (op. cit.). 

3 Univ. Col. Hosp. Mus. 550, W. 5. 

4 St. George's Hosp. Mus. Catalogue, L. ii. 

5 Coll. Surg. Mus. 1095 and 1U9G. 

6 Ibid 7 Trans., vol. xii. 



296 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

and stimulating applications. If a generally relaxed condition of the tis- 
sues throughout the body prevails, suitable tonic and analeptic measures 
are called for. 



WOUNDS OF THE LARYNX. 

Latin Eq. — Vulnera laryngis. 
French Eq. — Plaies du larynx. 
German Eq. — Wunden des Kehlkopfs. 
Italian Eq. — Ferite della laringe. 

Definition. — Incisions, punctures, contused or lacerated wounds of the 
larynx from without inward, whether homicidal, suicidal, or accidental. 

Etiology. — Wounds of the larynx are rare in military surgery, only 6 
cases occurring amongst 10,000 wounded. 1 In civil practice, however, 
owing to the frequency with which the part is injured in suicide, the in- 
jury is common. Out of 158 cases of cut-throat collected by Durham, 2 in 
61 the wound was inflicted on the larynx, and 45 were through the thyro- 
hyoid membrane. In 58 cases analyzed by Horteloup 3 86 occurred be- 
tween the lower margin of the hyoid bone and the upper edge of the first 
ring of the trachea. According to Malgaigne, 4 young men, when making 
suicidal assaults on the throat, as a rule wound themselves above the 
larynx; whereas in old men the injury is generally inflicted below the cri- 
coid cartilage. The reason of this difference is that old men usually find 
a difficulty in elevating the chin and throwing the head well back. Punc- 
tured wounds of the larynx are generally the result of thrusts made with 
a bayonet, 5 stiletto, or foil, or by some pointed piece of metal or a nail. 
These punctured wounds are apt to give rise to emphysema of the neck, 
sometimes causing serious dyspnoea. 6 Gunshot wounds are generally of 
a somewhat contused character, but a bullet will sometimes pass through 
the neck leaving only its track in the thyroid cartilage; or on the other 
hand it may carry away the greater part of the larynx. A solitary in- 
stance is on record in which a bullet fractured the thyroid cartilage with- 
out destroying the skin. 7 As a rule, the bullet does not remain in the 
larynx, but if not removed finds its way to the root of the neck. Four 
preparations illustrating gunshot wounds are to be found in the Army 
Medical Museum. 8 In the first instance the ball fractured the lower jaw, 
passed through the thyro-hyoid membrane, and carried away the epi- 
glottis. In the second the anterior and superior part of the thyroid car- 
tilage was carried away by a bullet, which also fractured the humerus. 
In the third the ball passed into the larynx from the side, and wounded 



1 Witte : Archiv. fur Klinische Chirurgie, Bd. xxi. lste C. p. 186. 

2 Holmes' Surgery, vol. ii. p. 441. 

3 Plaies du Larynx, etc. , Paris, 1809. See also a valuable Article in Pitha-Billroth's 
Handbuch, vol. iii. by Dr. George Fischer : Wunden des Kehlkopfs. 

4 Horteloup, op. cit. p. 17. 

5 Durham, op. cit. p. 447. 

6 Beach : New York Med. Journ., March, 1877. 

' George Fischer : Deutsche Chirurgie, 1880, Lief. 34, p. 132. 
8 Nos. 202, 048, 057, 1440. 



WOUNDS OF THE LARYNX. 297 

the epiglottis. In the fourth and last case the bullet stuck fast in the 
upper part of the thyroid cartilage. 

Symptoms. — Incisions into the larynx (except in the case of surgical 
operations) are almost invariably transverse. Considerable difference of 
effect is observed, according as the opening is large or small. In the for- 
mer case, if the cartilages are divided entirely through, the wound gapes 
widely through the action of the muscles which elevate and depress the 
larynx. There is not usually much hemorrhage, but asphyxia may occur 
rapidly through some part, such as a piece of the epiglottis or one of the 
arytenoid cartilages falling into the glottis and blocking it up. In exten- 
sive wounds of the larynx, the voice is usually altogether extinguished. 
In small wounds or punctures of the larynx the most prominent symptoms 
are the result of internal hemorrhage and emphysema of the cellular tis- 
sue of the neck, chest, or even of the whole body. A clot sometimes 
quickly forms in the trachea or bronchi, and causes death by suffocation. 
In all cases, if the first dangers of the wound are escaped, subsequent in- 
flammation with tumefaction and formation of pus is very likely to place 
the life of the patient in jeopardy. In illustration I need only refer to 
the case recorded by Sir C. Bell, 1 in which a girl plunged a small penknife 
into her larynx; some months later exuberant granulations arose which 
filled up the glottis and caused death by suffocation. One of the common- 
est sequelae is the formation of a dense web across the larynx, whilst more 
or less enlargement of the cartilages, from chronic inflammation, is seldom 
absent. Occasionally a fistulous aperture leading into the larynx remains 
after the surrounding parts have healed up, not only showing no tendency 
to spontaneous closure, but resisting all measures except those of a rhino- 
plastic character. In a case sent to me by Dr. Sutton, of Dover, there 
was an opening as large as a shilling several years after the wound was 
inflicted. 

Prognosis. — Out of 88 cases of large wounds 67 patients recovered and 
21 died. In 21 instances of small wounds there were 10 recoveries and 11 
deaths. 2 Few patients recover without some modification of the vocal 
function, but the prognosis in respect to this point depends on the rela- 
tion of the incision or puncture to the vocal cords. It will be remembered 
that the danger to respiration does not terminate with the healing of the 
wound or the relief of the first symptoms. Subsequent cicatricial narrow- 
ing of the windpipe may require that the air-passage should be opened, 
even if that operation was not at first required, or if tracheotomy was per- 
formed in the first instance it might either prevent the removal of the tra- 
cheal canula, or render tracheotomy necessary a second time. 

Treatment. — The general treatment will be discussed under the head 
of Cut-Throat, it being only necessary to remark here that, in the case of 
gunshot wounds, or jagged cuts, however produced, it is very important 
to see that any loose fragments of epiglottis, arytenoid cartilage, or mu- 
cous membrane, are altogether removed; and that in a punctured wound, 
any resulting emphysema should be relieved by scarification of the skin. 
The cicatricial narrowing of the windpipe, which so often results, must be 
treated by the mechanical measures described at page 284. 



1 Surgical Observations, vol. i. p. 45. 

2 Horteloup, op. cit. p. 86. 



298 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 



Burns of the Larynx. 1 

Samuel Cooper 2 and Marjolin* first called attention to the frequency 
of dyspnoea in cases of burn, but it remained for Kvland 4 to point out 
that this condition was frequently due to burning flame or highly heated 
air. Since then Durham 5 and Cohen fi have reported cases. In most of 
the recorded cases the upper portion of the body was the seat of the burn, 
but in some instances the lower extremities alone suffered. The symp- 
toms are generally great pain in the throat, difficulty of swallowing, dysp- 
noea, aphonia, and the presence of a quantity of black carbonaceous mat- 
ter in the sputa. The symptoms usually come on a few hours after the 
accident. On examining these cases great inflammation of the fauces is 
generally to be seen, and the larynx in one case, reported by Dr. Cohen, 
was in a state of acute oedema. There is generally great nervous prostra- 
tion. The progjiosis is very serious; it depends not only on the extent 
and depth of the burn, but also the age and vigor of the patient must be 
taken into consideration. 

The local treatment should consist in making the patient suck ice and 
using insufflations of morphia; but if there is much oedema, scarification 
should be employed, and, if necessary, tracheotomy must be performed. 



t 
FOREIGN BODIES IN THE LARYNX. 

Latin Eq. — Corpora adventitia in larynge. 
French Eq. — Corps etrangers dans le larynx. 
German Eq. — Fremde Korper im Kehlkopf. 
Italian, Eq. — Corpi stranieri nella laringe. 

Definition. — Foreign bodies generally introduced into the larynx from 
without, most frequently through the mouth during mastication or deglu- 
tition, and only very rarely entering through a wound in the neck. Occa- 
sionally, however, they pass upward from the trachea or oesophagus. 

Etiology. — A complete collection of all the foreign bodies that at one 
time or another have found their way into the larynx would probably 
comprise specimens of every known substance. 7 Flesh, bread, fragments 
of bones of all edible quadrupeds and fish, stones of various species of 
fruits, nutshells, grains of corn, peas, beans, shells of mollusks, coins, but- 
tons, pebbles, artificial teeth with their fittings, are examples of the for- 
eign matters that most frequently become impacted in the larynx. The 
first class of substances, i. e., those connected with alimentary matters, 

1 This subject might perhaps have been more conveniently considered in connection 
with Scalds of the Larynx (page 200), but having been hitherto omitted must be briefly 
referred to here. 

2 Diet, of Pract. Surg., art. Burns. 

3 Diet, de Medecine, art. Brulure. 

4 A Treatise on Diseases and Injuries of the Larynx and Trachea, p. 274, 1837. 

5 Holmes's System of Surgery, vol. ii. p. 4(50, second edition. 

6 Cohen: Inhalation, its Therapeutics and Practice. 187<'i. p. 2!>4. 

1 See Gross: Treatise on Foreign Bodies in the Air-passages, Philadelphia, 1854. 



FOREIGN BODIES IN THE LARYNX. 299 

usually gain admission during mastication, whilst the person is laughing 
or talking; less frequently during the act of deglutition. Foreign bodies 
of metallic composition are occasionally impacted in the larynx of children, 
who amuse themselves by putting coins, buttons, small toys, etc., in the 
mouth. In rarer instances teeth, real or artificial, or tooth plates, become 
loosened during sleep and drawn into the glottis. It is, indeed, very fre- 
quently during sleep that the metallic bodies mentioned above find admit- 
tance into the air-passages in children who have gone to bed with them 
in their mouths. An accident of this kind occurred to a lad at Wisbeach 
in the year 1876. ' The boy went to sleep with a toy-engine in his mouth, 
and during the night it passed into the windpipe. Dr. Bury, who was 
called to the case, found it necessary to perform tracheotomy. The cause 
of the sudden attack of dyspnoea was not known at the time, and some 
months later Dr. Bury sent the patient up to me at the Hospital for Dis- 
eases of the Throat, and I transferred the case to my principal clinical 
assistant, Dr. Samuel Johnson, now of Baltimore. The little engine was 
found to be so deeply embedded in the subglottic region that it could 
only be extracted after Dr. Johnson had performed thyrotomy. The pa- 
tient made a complete recovery, though his voice has remained up to the 
present time (July, 1879), slightly hoarse. Peas or puff-darts are some- 
times sucked in through tubes; and leeches applied inside the mouth will 
occasionally make their way downward, though more frequently these 
animals get into the larynx from drinking dirty water, an accident which 
has often happened to soldiers on march. Dr. Massei 2 succeeded in re- 
moving from the pharyngo-laryngeal sinus a living leech which had found 
its way into that situation whilst the patient was drinking some impure 
river water a fortnight previously. Foreign bodies may also become fixed 
in the larynx, having previously passed upward through the trachea or oeso- 
phagus. A curious case is related by Edwards, 3 of a boy net. eight, in 
whom a bronchial gland became detached, passed by an ulcerated opening 
into one of the bronchi, and was thence expelled up the trachea during 
violent exertion, so as to become impacted in the rima glottidis. The epi- 
glottis itself may be drawn into the larynx and become spasmodically fixed 
in that situation. Dr. Solis Cohen 4 remarks that this accident "usually 
occurs during eating," but that he has " known it occur during swallowing 
of saliva and threaten asphyxia." This author refers to a case reported 
by Riihle, 5 and adds that " it is not improbable that some cases of other- 
wise unaccountable sudden death at a meal may be due to this cause." 
If an inspiration be taken incautiously during the act of vomiting, as 
sometimes occurs in fits of drunkenness, some of the matters passing up 
from the stomach may be drawn into the larynx and cause suffocation. 
Foreign bodies may also gain access to the cavity of the larynx directly 
from without, i. e., by penetrating its walls when driven forcibly, as in the 
case of bullets, flying fragments of metal, stone, etc. Some idea of the 
frequency with which foreign matters become fixed in different parts of 
the air-passages, may be gathered from an analysis of 166 cases made by 
Bourdillat. 6 Of these in 80 instances the foreign body was arrested in the 
trachea, and 35 in the larynx, in 26 in the right bronchus, and in 15 in 



1 Archives of Clin. Surg., Dec. 187G. - II Morg,-ig:ii, Oct., 1874. 

3 Med.-Chir. Trans., vol. xxxvi. * Op. cit. , second edition, p. 615 et seq. 

5 Op. cit. p. 13. ' 

6 Gazette Med., 1861, p. 135. See also a further paper by the same author on Three 
Hundred Cases of Foreign Bodies in the Air-Passages. — Gazette Med., 1868. 



300 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

"the left bronchus. According to Durham, 1 however, the larynx is the most 
frequent site of impaction of a foreign body. Out of 15 cases collected by 
that writer, in 7 the larynx arrested the foreign substance, in 5 the tra- 
chea, in 2 the right bronchus, and in 1 the left bronchus. 

Symptoms. — These vary considerably, according to the size of the for- 
eign body and the mode in which it has become impacted. If fixed in 
the rima glottidis, and large enough to fill that opening, death may be 
almost instantaneous, unless the convulsive efforts of the patient at res- 
piration succeed in dislodging it. On the other hand small bodies, such 
as fish bones, may remain in the larynx for an indefinite period without in- 
terrupting respiration, merely giving rise to cough and sensations of dis- 
comfort in the part. 2 Sometimes even the temporary impaction of a for- 
eign body gives rise to hemorrhage from the surface of the mucous mem- 
brane, and Sommerbrodt 3 has reported a case in which the mere contact 
of a foreign body in the act of deglutition led to the immediate formation 
of a small blood-cyst on the dorsal surface of the posterior wall of the 
larynx. The cyst was opened and the patient at once cured. In many 
cases when the presence of the foreign body does not at first directly ob- 
struct respiration, it does so afterward indirectly by causing inflamma- 
tion and tumefaction of the soft parts of the larynx. In another class of 
cases the foreign body may at first allow the freedom of respiration, but 
subsequently take up an altered position, 4 which immediately menaces 
life. Thus a substance of irregular shape may pass the glottis and be- 
come arrested in the trachea, and after a variable interval be driven up- 
ward during a fit of coiiffhinff, so as to become firmlv wedo-ed into .the 
rima glottidis. Under these circumstances sudden death may be the re- 
sult. When the foreign body is impacted in one of the ventricles 5 it can- 
not generally be moved, and if it passes into both ventricles it will most 
likely require to be broken or crushed before it can be extracted (see case, 
page 302). In some instances considerable danger accrues, not from the 
position of the foreign body, or from inflammation, but from violent 
spasm of the glottis, brought about by the irritation applied directly to 
the part. As a rule great anxiety and terror on the part of the patient 
accompany the entrance of any foreign body, however small, into the air- 
passages, and in many cases somewhat mask the real importance of the 
accident. In those cases where the foreign body remains in the larynx 
without causing immediate danger to life by asphyxia, pain is a promi- 
nent symptom. Sharp and angular bodies of any size cause very acute 
and continuous pain when they become impacted so as to press against 
the contiguous soft parts, and, of course, quickly give rise to high inflam- 



1 Holmes's System of Surgery, vol. ii. p. 477. 

2 The case of the poet Anacreon, who is supposed to have died from a grape-stone 
having lodged in the larynx (Pliny. 1. vii. c. v.), which is opposed to these) instances, 
is probably an example of " poetical justice " and has reference to the previous mode 
of life said to have been pursued by Anacreon. Retribution, however, did not over- 
take the rollicking poet until he was 85 years old ! 

3 Berlin, klin. Wochenschrift, 1878, No. 18. 

4 See a case in point by Porter, Dub. Med. Press, Feb. 9, 1859. 

6 See the case of a button-mould fixed in the lefr ventricle of the laryrx, and ex- 
tracted after six weeks by laryngotomy (Pelletan : Clin. Chir. . t. i. p. 8 . Also an in- 
stance by Desault. where a cherry-stone remained in one of the laryngeal ventricles 
for two years, at the end of which time the patient died from disease of the larynx 
(CEuvres Chir., t. ii. p. 258). In a case mentioned by Sir Thomas Watson, a piece of 
gold remained for years in a similar position without detriment to the patient (Pract. 
of Physic, fifth edition, vol ii. p. 261). 



FOREIGN BODIES IN THE LARYNX. 301 

mation. The position taken up by any foreign body in the larynx can 
usually be seen on using the laryngoscope. 

Diagnosis. — The presence of a foreign body in the larynx can seldom 
remain for long a matter of doubt. The history of the case is usually 
clear, and laryngoscopic examination verifies or disproves the statement 
made by the patient. In the case of children and hysterical females, 
however, the diagnosis cannot always be arrived at immediately. A child 
may come home complaining of its throat, and in a short time present 
symptoms closely resembling croup. The little sufferer has swallowed 
something used as a plaything, such as a button, small coin, or toy, but 
either forgets the circumstance or is afraid to tell it. By a careful con- 
sideration of all the facts connected with the case, however, and by laryn- 
goscopic examination, the true nature of the affection may generally be 
brought out. As will be hereafter explained, hysterical persons, suffer- 
ing from hyperesthesia or paresthesia of the larynx, often erroneously 
fancy that something is sticking in the part. Such cases have generally 
only to be seen to be recognized. 

Prognosis. — Death, of course, sometimes follows immediately on the 
accident. ^ T hen this is delayed, there is always great danger as long as 
the foreign body remains in the larynx or air-passages. A fatal result 
may occur after a time from two different causes, viz.: either the foreign 
body may become dislodged, and assuming an altered position, may close 
the glottis and suffocate the patient in a few minutes ; or the amount of 
inflammation and tumefaction of the soft parts of the larynx may more 
gradually lead to the same result. Even after the foreign body has been 
removed, a cautious prognosis must be given as long as there are any 
symptoms of local inflammation. 

Treatment. — The indication of paramount importance is, of course, to 
remove the foreign body at the earliest opportunity. Mr. Durham 1 has 
collected 55-4 cases of foreign bodies in the air-passages, in 283 of which 
the substance was extracted by opening the windpipe or otherwise by 
the medical attendant, whilst in 271 the efforts of nature were left un- 
aided, except in 51 cases where emetics were given. In the first set of 
cases the deaths amounted to 70 (24.8 percent.), and in the second set 
to 115 (42.5 per cent.). Great encouragement is thus given to operative 
procedures, but it must be taken into consideration in drawing inferences 
from these tables that death without the expulsion of the foreign body 
occurred in the cases not operated on 95 times. Doubtless in many of 
these instances the fatal result was immediate, before surgical aid could 
be obtained or operative measures adopted. On the other hand, in the 
cases subjected to operation, the foreign body was probably fixed in a po- 
sition which admitted of delay, and of course materially lessened the dan- 
ger of the accident. 

If the symptoms are not urgent, a laryngoscopic examination should 
be made, and the foreign body, if possible, removed with the aid of for- 
ceps. The common laryngeal forceps generally answer best, though in 
the case of children, on account of the small size of the larynx, the tube- 
forceps are more convenient. But if the patient be found at the last 
gasp, the first action of the surgeon should be to open the trachea and 
introduce a canula. Respiration being provided for, the laryngeal mirror 
may be subsequently used, and the foreign body removed per vias natu- 
rales. In some cases the foreign body cannot be extracted until it has 



Op cit. p. 488. 



302 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

broken into fragments, as in an instance (hereinafter described) which 
came under my notice. In some cases, either before or after tracheo- 
tomy, according to the urgency of the symptoms, the foreign body may 
be got rid of by placing the patient head downward and shaking the 
body. This procedure, which is more likely to answer in the case of 
smooth and roundish bodies, such as coins, buttons, and stones, is more 
particularly applicable in the case of foreign bodies lodged below the 
larynx, and will be found described in detail under Foreign Bodies in the 
Trachea. Sometimes after reducing the local inflammation by suitable 
remedies, a foreign body, previously immovably fixed, can be easily ex- 
tracted. This fact was illustrated by a remarkably successful case of Dr. 
Whistler's, 1 in which, with the aid of the laryngoscope, he removed a 
lamella of bone, measuring nearly an inch by three-fourths of an inch, 
from below the vocal cord six weeks after it had become firmly embedded 
in the laryngeal tissues. If this method fails, recourse must be had to 
thvrotomy, practised in the same manner as for the removal of growths 
from the larynx; 2 but owing to the risk of producing permanent aphonia, 
the laryngeal cartilages, should, if possible, be left intact. As the ope- 
ration approaches completion, some caution is necessary, in order to 
prevent the foreign body slipping down into the trachea after the lar- 
ynx is laid open. When seen, the object should be grasped firmly with 
forceps and extracted. Not unfrequently, however, a forcible expiration 
through the wound expels the foreign body as soon as the windpipe is 
opened. 

Before removing the tracheal canula and closing the opening, great 
care should be taken to ascertain that the patient can breathe freely 
through the larynx. After the injured parts have regained their natural 
condition, an experiment may be made by corking the canula, which may 
afterward be entirely removed as soon as it becomes evident that the pa- 
tient is able to breathe freely for an indefinite period through the larynx. 
The following case is a good illustration of the impaction of a foreign body 
in the larynx : 



CASE OF IMPACTION OF A LAMELLA OF BONE TRANSVERSELY IN THE VEN- 
TRICLES. 

John B., aged fifty, a laborer, suffering from aphonia, dyspnoea, and 
dysphagia, was brought to me on September 29, 18GG, by Mr. John Gum- 
ming. The patient stated that three days previously, whilst taking some 
soup (made from sheep's head) he suddenly felt choked by something 
" going the wrong way." He tried to get it up with his ringers, but did 
not succeed. Subsequently, he vomited violently, and after bringing up 
large quantities of blood, fell insensible on the floor. On examining him 
with the laryngoscope, a piece of bone was seen to be lodged horizontally 
in the larynx, just above the level of the vocal cords, in such a manner 
that it completely blocked up the anterior third of the laryngeal canal 
(Fig. A). The bone could not be moved with a laryngeal probe, and after 
repeated unsuccessful efforts to seize it with forceps, the symptoms being- 
very urgent, tracheotomy was performed. On October 5th Sir William 
Fergusson attempted, with various instruments, to remove the bone ; but 
it was so impacted that it could not be dislodged. That eminent surgeon 



Lancet, Dec. 2, 1870. 2 See page 237. 



NERVO-MUSCl'LAR AFFECTIONS OF THE LARYNX. 



303 



recommended that, if after a delay of a few days, the bone was still im- 
pacted, the thyroid cartilage should be divided, and the bone removed 
through the wound. On October 14th I succeeded in passing a blunt hook 



tin 



n lamina 




v 



behind and below the bone, and in this manner brought up 
of bone about half an inch 
across in each direction. On 
the following day a small 
piece of bone was seen 
projecting from the right 
ventricle (Fig. B). After 
passing an instrument be- 
low, and slightly moving 
the fragment, the patient 
coughed up a piece of bone, 
about half an inch long, and 
a quarter of an inch wide, -r ■--'■ .: 

covered on one side with u X 

gristle. On putting the pie- 
ces of bone together, they 
made altogether a lamina 
three-quarters of an inch 
long and half an inch wide 
(Fig. C). This had been 
impacted horizontally with 
its long diameter across the 
larynx in such a manner 
that about three-eighths of 

an inch had extended into the right ventricle, and rather less than a quar- 
ter of an inch of the bone into the left ventricle ; in this way the bone 
could not move to the smallest extent either upward or downward. It 
will be seen therefore that the bone could only be removed by fracturing 
the portion in one of the ventricles, and that the portion in the right ven- 
tricle was separated from the main part by the operation on the 14th. 
On the 16th the patient was discharged cured. The bone was shown at 
the Pathological Society, and further details will be found in the Transac- 
tions (vol. xviii. p. 27 et seq.). 



/ 



Fig. 87. — A shows the view of the larynx as first seen : a is a 
horizontal lamella of bone, whose outer extremities pass into the 
ventricles of each side. B shows the view of the larynx, after 
the bone has been broken, and the central portion and that pass- 
ing into the left ventricle have been removed : b is the fractured 
edge of the fragment of the bone remaining in the right ventricle. 
C is the bone put together after removal : a corresponds to the por- 
tion indicated by the same letter in A ; r is the part which pass- 
ed into the right ventricle ; I the portion which rested in the left 
ventricle, and e the surface of the bone that was hidden by the 
epiglottis. 



[NERVO-MUSCULAR AND SENSORY AFFECTIONS OF THE 

LARYNX. 



Before proceeding to describe the various laryngeal neuroses in detail, 
it is desirable to make a few remarks here on the classification of these 
important diseases. 

Nervous affections of the larynx may be divided primarily into two 
classes, viz., (1) neuroses of sensation, and (2) neuroses of motion. Con- 
cerning the first class, our knowledge is very limited, not only on account 
of the rarity of the lesion, but also because the subject has hitherto re- 
ceived little attention from laryngoscopists. Disturbances of the motor 
apparatus of the larynx have, however, been more carefully studied, and 



304 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

the observations of Ziemssen, 1 Gerhardt, 2 Riegel, 3 and others have pro- 
vided us with a more complete, though still imperfect, picture of their 
origin, course, and issue. 

There are four kinds of disturbance of the sensory functions of the 
laryngeal mucous membrane, viz., (1) anaesthesia, (2) hyperesthesia, (3) 
paresthesia, and (4) neuralgia or hyperalgesia. 

Neuroses of motion may be conveniently divided into the two natural 
classes, viz., (1) loss of power, or paralysis, and (2) perverted power, or 
spasm. 

Under loss of power we have : 

1. Paralysis from disease or injury of that portion of the medulla oblon- 

gata which constitutes the floor of the fourth ventricle ; 

2. Paralysis from disease or injury of the spinal accessory nerve ; 

3. Paralysis from disease or injury of the pneumogastric nerve ; 

4. Paralysis from disease or injury of the superior laryngeal nerve ; 

5. Paralysis from disease or injury of the recurrent laryngeal nerve; and 

6. Paralysis of individual muscles, or sets of muscles — a class of affec- 

tions which, though generally of myopathic nature, can be most 
conveniently considered in this subdivision. 

Under perverted power we have : 

1. Spasm of the adductors of the vocal cords and its cognate affections ; 

and 

2. Spasm of the tensors of the vocal cords.] 



ANESTHESIA OF THE LARYNX. 

Latin Eq. — Anaesthesia laryngis. 
Fi*ench Eq. — Anesthesie du larynx. 
German Eq. — Anaesthesie des Kehlkopfs. 
Italian Eq. — Anestesia della laringe. 

Definition. — Loss of sensibility of the mucous membrane of the la- 
rynx, due to central or peripheral disease of the nervous system. 

Etiology. — This condition, as a serious manifestation, appears to be 
confined to cases of diphtheritic and bulbar paralysis. Chairou 4 remarks 
that anesthesia of the epiglottis and larynx is an invariable concomitant 
of hysteria ; but, although there is sometimes a slightly diminished sensi- 
bility of the pharynx in these cases, I have never observed that the mu- 
cous membrane of the larynx was at all obtuse to direct impressions. 
Romberg 5 states that in severe cases of cholera there is impaired sensi- 
bility of the mucous membrane of the larynx. 

1 Cyclopaedia of Medicine, vol. vii. p. 093. 

2 Virchow's Archiv, vol xxi. ; Volkmann's Sammlung Klin. Vortriige, No. 36, 
1872. Laryngologische Beitrage, D. Archiv f. Klin. Med., Bd. xi. p. 575, 1873. 

3 Ibid. : Bd. vi. p. 37, 1809 ; Bd. vii. p. 204. 1870 ; and Volkmann's Samm. Klin. 
Vortriige. No. 95, 1875. 

4 Etudes Chir. sur l'Hysterie, Paris, 187C. 

5 Huf eland's Journal der pract. Heilkunde, Feb., 1832. 



ANESTHESIA OF THE LARYNX. 305 

Symptoms, — In some cases the loss of sensation does not reach below 
the vocal cords, whilst in others the anaesthesia extends to the greater 
part of the mucous lining of the trachea. 1 The affection varies also in in- 
tensity ; sometimes it is so complete that any part of the epiglottis or 
laryngeal cavity may be touched with a sound without producing any sen- 
sation or movement of the larynx ; whilst in other cases it is incomplete, 
a sensation being experienced, but not giving rise to the reflex act of 
coughing. The anaesthesia may also be confined to one side, or may be 
bilateral. Dysphagia often occurs in these cases, food, especially in the 
liquid form, having a tendency to pass into the windpipe. This phen- 
omenon was formerly supposed to result because the insensible condition 
of the mucous membrane of the larynx allowed particles to enter the air- 
passage, but it would appear that the actual cause of the penetration of 
food, is the associated paralysis of the muscles depressing the epiglottis. 
The motor phenomena commonly coexisting with anaesthesia will be 
found described at p. 317. 

Prognosis. — Except in cases of bulbar paralysis, laryngeal anaesthesia 
generally terminates in recovery in a period varying from four to six 
weeks. It must not be forgotten, however, that in extreme cases, if prop- 
er means have not been taken to prevent the passage of food into the 
windpipe, death is likely to result from pneumonia. 

l)iagnosis. — In the absence of any obstruction of the pharynx or oeso- 
phagus, the tendency of food to pass into the larynx when the patient is 
swallowing strongly points to the probable existence of anaesthesia, but 
certainty can only be attained with the laryngeal probe. 

Pathology. — All cases of true anaesthesia of the larynx must be due 
to loss of function of the superior laryngeal nerve, or of certain fibres in 
the pneumogastric nerve which ultimately form the superior laryngeal 
nerve, or a minute portion of the nucleus of the pneumogastric nerve must 
be involved in the floor of the fourth ventricle. The change which takes 
place in the nerve-structures in diphtheria will be found described at page 
114, and in greater detail in my recently published work. 2 The pathol- 
ogy of bulbar paralysis is contained in the ordinary text-books of medi- 
cine. 

Treatment. — The local application of electricity is the most important 
remedy in this class of diseases. I formerly only employed faradism, but 
during the last five years I have, as a rule, used both the galvanic and in- 
duced currents. In any case the current should be sufficiently strong to 
cause discomfort, but not pain. In order to carry out this treatment, either 
the double laryngeal rheophores (page 186) or my single electrode (page 186) 
may be used. If the latter instrument is employed the necklet should be 
worn, so that its metal disk lies over some portion of the course of the 
superior laryngeal nerve between the greater cornu of the hyoid bone, and 
the base of the arytenoid cartilage. In either case the instrument may 
be introduced daily into the larynx, and used six or eight times at a sit- 
ting. Whilst the local treatment is being thus pursued, it is also advis- 
able to improve the health of the patient by general tonics, and especially 
by the administration of strychnine; and if, in swallowing, food enters 
the larynx, the patient should be fed with the oesophageal tube. In in- 
troducing the instrument care should be taken not to pass it into the la- 

1 See Schnitzler : Wiener Med. Presse, Nos. 46 and 48, 1873. See also Leube : D. 
Arch. f. Klin. Med., Bd. vi. p. 260, 1869; and Acker, Ibid.,Bd. xiii. p. 416, 1874 
- Diphtheria, 1879, p. 38 et seq. 

20 



306 DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. 

rvnx, an accident which is not unlikely to occur in this class of cases. 
The tube should therefore be guided down the throat as far as possible 
by the finger, and when in situ, if there be any doubt as to its position, 
the patient should be desired to produce a vocal sound before any food is 
injected. 

CASES OF ANAESTHESIA OF THE LARYNX AFTER DIPHTHERIA. 

Case 1. — On November 5, 1876, two sisters, suffering from anaesthe- 
sia of the larynx, came under my notice. The first case was that of Mrs. 
W., aged forty-three, who was recovering from diphtheria when I first saw 
her. Three of her children had been attacked with the disease, and as 
they were recovering she became affected. When I saw her the pharynx 
was slightly cedematous and red. There was abundant frothy secretion, 
but no false membrane, and she was able to swallow with slight difficulty. 
On November 8th the dysphagia had greatly increased, she became much 
weaker, and could scarcely stand. In attempting to walk her gait was 
unsteady, and she once fell down in walking across her room. On No- 
vember 9th the patient was unable to swallow at all, everything passing 
into the windpipe, and giving rise to paroxysms of coughing. Her voice 
was weak and nasal, but distinctly phonetic. The uvula and palate were 
both completely paralyzed and insensible, and on making a laryngoscopic 
examination the epiglottis was seen to be slightly inflamed, and retracted 
against the back of the tongue, so that only its under surface w T as visible. 
The vocal cords appeared healthy in color, and their adductive action was 
normal. On introducing a laryngeal probe into the larynx and touching 
the epiglottis and vocal cords no effect was produced, but the action of 
the vocal cords prevented the passage of the sound into the subglottic 
region. On placing the finger on the crico-thyroid muscle, and directing 
the patient to speak, the muscle was felt to contract normally. 

This patient was fed by means of the oesophageal tube twice a day for 
a fortnight, when to a great extent she had recovered her power of swal- 
lowing; both galvanic and induced currents of electricity were also applied 
daily for a month to the pharynx and larynx. Strychnia was administered 
in this case, but after taking -g^th of a grain three times a day for two days, 
toxic effects were produced, and the drug was accordingly discontinued, 
and quinine prescribed. By the middle of December the general health 
was greatly improved; the patient had quite recovered her power of walk- 
ing, but she had occasional trouble in deglutition, and was attacked with 
paroxysms of choking and coughing during meals. On referring to my 
note book I find that complete insensibility of the larynx remained for 
ten days after I had first noticed it. After this it gradually disappeared, 
but the attacks of choking and violent couirhin<r in swallowing continued 
some weeks after the larynx had recovered its sensibility to the impression 
of the laryngeal sound and the epiglottis had regained its power. The 
voice was still nasal, and there was paresis of the palate on January 1st. 
The patient left town at this period, and I heard that her voice did not be- 
come quite normal till the middle of February. 

Case 2. — Miss A., aged forty-one, who had assisted in nursing the 
children of her sister (the patient whose case has just been recorded), also 
suffered from an attack of diphtheria. About ten days after recovery 
difficulty of swallowing came on — the symptoms being very much the 
same as those described in the case of Mrs. \Y. — but the voice was com- 
pletely lost, and she also had dipoplia. Unlike the previous case the power 



ANESTHESIA OF THE LARYNX. 307 

of the lower extremities was perfect. The palate was found to be para- 
lyzed, and there was complete insensibility of the larynx on introduction 
of the laryngeal sound. The adductor of the right vocal cord was also 
paralyzed, and the left cord moved feebly toward the median line. At- 
tempts were made to ascertain whether the crico-thyroid muscle was para- 
lvzed, but the non-action of the adductors rendered it impossible to ascer- 
tain larvn°:osco